Can someone help me think through this question?

[Mkakids]

Just had an exam, and the question below was on it (not exact, I just typed it from memory). Two answers were obviously incorrect and two were both, in my opinion, correct. I answered with one, and a friend with the other (we don't know who was correct yet either), so we were trying to figure out the correct way to read/interpret this question to lead to the "most correct" answer.

Which one would you choose and why?

During suctioning your patient's tracheostomy becomes dislodged and is not easily replaced. What it the priority action by the nurse?

A) Cover the tracheostomy and administer oxygen

B) Stabilize the patients oxygen levels and notify the physician immediately.

The book says the following about it:

"Tracheostomy becomes dislodged and is not easily replaced: Notify the primary care provider immediately. This is an emergency situation. Cover the tracheostomy stoma. Assess the patient's respiratory status. Anticipate the need for maintaining ventilation using a manual resuscitation"

[katyq82]

So what I was told to do when faced with a question in which there is more than one correct answer is to think about what would happen to the patient if you did only what is stated in the response and nothing else. Which one would best maintain patient safety? That is your priority action.

In this case I would go with B, because "stabilize the patient's oxygen level" implies that you are delivering ventilation but unlike choice A, it states that you notify the physician/get help as well. If you only did A, you might keep the pt. alive but you wouldn't be solving the problem.

This is what my med-surg book says about that scenario,

"If you cannot secure the airway, notify a more experienced nurse, respiratory therapist, or physician for assistance. Ventilate with a bag-valve mask. If the patient is in distress, call the Rapid Response Team for help." (Ignatavicius)

[Mkakids]

thank you! I also went with B, for the same reason but I struggled with it because, in my experience, notify the physician is rarely the correct answer.

[akulahawkRN, ADN, RN, EMT-P]

thank you! I also went with B, for the same reason but I struggled with it because, in my experience, notify the physician is rarely the correct answer.

In this case, it is the most correct answer because it is the one that provides for patient safety. Answer "A" is within what a nurse can do, while answer "B" implies taking actions to stabilize the patient while alerting the appropriate resource to correct the underlying problem of the dislodged trach tube. Answer "A" does not address the underlying problem.