# A patient is 18 hours post-op from a tracheostomy. The patient suddenly coughs forcefully, the tracheostomy tube dislodges and is now lying on the chest, and the patient is in respiratory distress. Which is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372800&lang=en > language: en > subject: Complications of Procedures > category: ROR ## Question A patient is 18 hours post-op from a tracheostomy. The patient suddenly coughs forcefully, the tracheostomy tube dislodges and is now lying on the chest, and the patient is in respiratory distress. Which is the nurse's priority action? ## Option 1. Reinsert the same tracheostomy tube using sterile technique through the stoma and then call for help. 2. Hold the stoma open with a curved hemostat or tracheal dilator, call rapid response, deliver oxygen by bag-valve mask over the mouth and nose with the stoma temporarily occluded, and prepare for emergent reinsertion or oral intubation. **✔ Correct answer** 3. Apply a sterile occlusive dressing over the stoma and administer oxygen by face mask. 4. Begin chest compressions and prepare for cricothyrotomy. **Correct answer: 2** ## Explanation A tracheostomy that dislodges within the first 7 days carries the highest risk because the stoma tract is immature and can rapidly close. Reinsertion in this window is best performed by experienced staff, often the surgical team, because a false passage is easy to create. The nurse's emergency response is to keep the stoma patent with a curved hemostat or tracheal dilator while calling for help, and to oxygenate immediately. Oxygenation in this scenario is by bag-valve mask covering the mouth and nose with the stoma temporarily occluded — air can pass through the patient's upper airway because the stoma is immature and not the only route. Choice 1 risks creating a false passage. Choice 3 fails to oxygenate. Choice 4 misreads a respiratory emergency as cardiac arrest. ## In-depth explanation Tracheostomy management is divided sharply by stoma maturity. Within the first 7 days the stoma tract is immature, friable, and prone to close or to develop a false passage on attempted reinsertion. The emergency response to dislodgement in this window: hold the stoma open with a curved hemostat, tracheal dilator, or the patient's obturator if available; call rapid response and the surgical team; oxygenate by bag-valve mask over the mouth and nose with the stoma temporarily occluded, since the upper airway is patent; prepare for replacement of the tube by experienced staff or oral intubation if reinsertion fails. After day 7 the tract is mature and the same nurse may safely reinsert with sterile technique. Bedside readiness for any tracheostomy includes obturator, two spare tubes (same size and one size smaller), curved hemostat, tracheal dilator, and suction equipment. ## Clinical scenario A patient is **18 hours post-op from a tracheostomy**. After a forceful cough, the **tracheostomy tube dislodges and is now lying on the chest**, and the patient is in **respiratory distress**. ## Key concepts - **Stoma Maturity** — Within the first 7 days the stoma tract is immature, friable, and prone to close or false-passage formation. After 7 days the tract is mature and reinsertion by trained staff is generally safe with sterile technique. - **Emergency Bedside Supplies** — Obturator, two spare tubes (same size and one size smaller), curved hemostat, tracheal dilator, suction equipment. Stocked at the bedside for any patient with a tracheostomy. The obturator inserted into the spare tube allows reinsertion through the stoma. - **Bag-Valve Mask Over Mouth and Nose** — In an immature tracheostomy with dislodgement, oxygenation is by BVM over the mouth and nose with the stoma temporarily occluded; air passes through the patient's upper airway because the stoma is not the only route. Once stoma is mature, ventilation through the stoma is preferred when possible. ## Related questions - [A patient on mechanical ventilation has bilateral infiltrates on chest x-ray, no signs of …](https://mymerci.kr/pages/nclex_q.php?qn_id=372717&lang=en) - [A 64-year-old patient three days post-MI has BP 84/62, HR 124, distant heart sounds, jugul…](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=en) - [A 64-year-old patient is post-op day 6 from a small bowel resection. 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