A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
Loose tracheal secretions
Hypoactive bowel sounds
High-pitched sound on inspiration
Client report of pain at the incision
The Correct Answer is C
Choice A reason:
Loose tracheal secretions are incorrect. While this could lead to airway issues if not managed, it's not as urgent as stridor.
Choice B reason:
Hypoactive bowel sounds are incorrect. Bowel sounds can be affected by anaesthesia and the surgical procedure, but they are not as immediately critical as airway issues.
Choice C reason:
High-pitched sound on inspiration. A high-pitched sound on inspiration, also known as stridor, can indicate a potential issue with the airway or breathing. Stridor can occur due to narrowing or obstruction of the upper airway, which can be particularly concerning after a thyroidectomy. It could suggest edema, bleeding, or damage to the laryngeal nerves, which are critical for vocal cord function and airway control. Stridor could potentially lead to airway compromise, making it a priority to report to the provider for immediate evaluation and intervention.
Choice D reason:
Client report of pain at the incision is incorrect. Pain management is important, but it's not an immediate threat to the client's airway or overall condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.It might also prematurely suggest stopping the medication without discussing potential consequences or alternatives.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
Correct Answer is A
Explanation
Choice A Reason:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.
Choice B Reason:
Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.
Choice C Reason:
Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.
Choice D Reason:
Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.
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