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 A
Explanation
Choice A Reason:
Wearing a lead apron when providing client care is appropriate. When caring for a client who is receiving internal radiation therapy, the nurse should take appropriate safety measures to minimize their exposure to radiation. Wearing a lead apron when providing care to the client helps shield the nurse's body from radiation exposure and reduces the risk of harm.
Choice B Reason:
Allowing visitors to hold the client's hand is inappropriate. Visitors should also be educated about radiation safety measures and should not be encouraged to have close contact with the client during internal radiation therapy.
Choice C Reason:
Leaving the door to the client's room open is inappropriate. Closing the door to the client's room can help contain radiation and limit its spread to other areas.
Choice D Reason:
Placing the dosimeter badge on the client's bed is inappropriate. The dosimeter badge should be worn by healthcare personnel to measure their radiation exposure. Placing it on the client's bed does not accurately measure the nurse's exposure and is not the correct use of the badge.
Correct Answer is D
Explanation
Choice A Reason:
Generalized abdominal pain - Abdominal pain may be present in peritonitis, but it can develop after other signs and symptoms.
Choice B Reason:
Increased heart rate - An increased heart rate can be a response to infection, but it is not the earliest indicator of peritonitis.
Choice C Reason:
Fever - Fever can also be a sign of infection and peritonitis but may not be the earliest manifestation in all cases.
Choice D Reason:
Cloudy effluent
The earliest indication of peritonitis in a client undergoing peritoneal dialysis is often the presence of cloudy or turbid peritoneal dialysis effluent (fluid). Cloudy effluent can indicate the presence of infection or inflammation in the peritoneal cavity, which is a significant concern in peritoneal dialysis. It's crucial for clients and their partners to recognize this early sign and seek medical attention promptly.
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