Nokea
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately.
Rationale:
1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel.
2. Immediate provider notification is crucial to prevent potential complications.
3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise.
4. Contacting the provider promptly ensures timely intervention and appropriate next steps.
Summary:
A: Notifying the operating room is premature and unnecessary at this point.
B: Pulsation may not always be normal and warrants immediate action.
C: Removing the tube without professional guidance can be harmful to the client.