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.
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Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Taking an antacid 30 minutes before taking ciprofloxacin is not necessary. Ciprofloxacin should generally be taken on an empty stomach, either 1-2 hours before or 2 hours after meals, but antacids containing aluminium, magnesium, or calcium can interfere with its absorption.
Choice B Reason:
Drinking 2 to 3 L of fluids daily is correct. For a client with chronic urinary tract infections who is taking ciprofloxacin, the nurse should instruct the client to increase fluid intake to maintain good urine flow and help flush out bacteria from the urinary system. Adequate hydration can contribute to preventing and managing urinary tract infections.
Choice C Reason:
Taking a laxative to prevent constipation is not directly related to ciprofloxacin use. While constipation can be a side effect of some medications, it is not a primary concern with ciprofloxacin.
Choice D Reason:
Monitoring heart rate is not a typical instruction related to ciprofloxacin use. While ciprofloxacin can have potential effects on heart rhythm (especially in high doses), this is not a common aspect of its use and does not typically require daily monitoring of heart rate.
Correct Answer is A
Explanation
Choice A reason:
Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or
Choice B reason:
Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.
Choice C reason:
Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.
Choice D reason:
Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.
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