A client with a tracheostomy being mechanically ventilated has a pulse oximetry reading of 85%,heart rate of 113 beats/min,and respiratory rate of 30 breaths/min.The client is restless,and crackles and rhonchi are auscultated over both lungs.Which action should the nurse take?
A) Call the respiratory therapist to check the ventilator settings.
B) Provide endotracheal suctioning.
C) Provide tracheostomy care.
D) Notify the physician of the patient's signs of fluid overload.

Question

Quizplus · Accepted Answer

The client's low pulse oximetry reading, high heart rate, and high respiratory rate combined with restlessness and adventitious lung sounds suggest that the client may have excessive secretions in the tracheostomy tube or in the airways. Endotracheal suctioning can help remove the mucus from the airways, improve oxygenation, decrease work of breathing, and reduce the risk of complications such as infection and atelectasis. The other options may also be appropriate depending on the client's condition, but they do not directly address the current priority of managing the airway and improving gas exchange.

A Client with a Tracheostomy Being Mechanically Ventilated Has a Pulse