A patient is admitted to the intensive care unit with a tracheostomy tube. While repositioning the patient, the nurse hears sudden gurgling sounds, and the patient displays respiratory distress. The nurse notes the tracheostomy tube has completely dislodged from the stoma. The tracheostomy was placed 2 days ago. What is the immediate priority nursing action?

Answer and explanation

Correct answer: A. Call for help, provide bag-valve-mask ventilation with 100% O2, and avoid blind reinsertion

  1. Step 1: A tracheostomy tract is immature (not epithelialized) within the first 7 days following surgical creation.
  2. Step 2: Attempting blind re-insertion can easily cannulate the pretracheal false tissue space, causing total airway occlusion. The nurse must call for emergent assistance and maintain oxygenation via bag-valve-mask over the upper airway while occluding the stoma.
Answer
Call for immediate emergency help, maintain the airway using a bag-valve-mask with 100% O2 over the mouth/nose while covering the stoma, and do not blindly reinsert into an immature tract.
Why not the others: 'Forcing the tube back' creates a fatal pretracheal false passage; 'Leaving the patient unattended' violates emergency life safety standards; 'Packing the stoma with dry gauze' prevents stomal venting and does not secure alveolar ventilation.

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