A patient has just arrived on the unit after a thyroidectomy. Which action would the nurse take first?
Check the blood pressure and pulse.
Observe the dressing for bleeding.
Support the patient's head with pillows.
Assess the patient's respiratory effort.
The Correct Answer is D
Choice A reason: Checking the blood pressure and pulse is important as part of the routine monitoring of vital signs to assess the patient's hemodynamic status. However, it is not the first action to take following a thyroidectomy. Ensuring that the patient's airway is clear and that there is no respiratory distress is paramount, as any compromise in the airway can lead to life-threatening situations. Blood pressure and pulse can be checked after confirming the patient is breathing properly.
Choice B reason: Observing the dressing for bleeding is also important because post-operative bleeding can be a serious concern. However, this action should follow the assessment of the patient's airway. If the patient is experiencing respiratory distress, addressing the airway takes precedence. Once it is confirmed that the airway is clear, then the nurse can check for bleeding and ensure the dressing is intact.
Choice C reason: Supporting the patient's head with pillows is beneficial for comfort and proper positioning, especially to avoid strain on the surgical site. However, positioning should not be the first priority. Ensuring that the patient's airway is clear and that there is no respiratory compromise is the most urgent concern. Proper positioning can be done after confirming that the patient is breathing adequately.
Choice D reason: Assessing the patient's respiratory effort is the first and most critical action. Following a thyroidectomy, there is a risk of respiratory complications due to potential swelling, bleeding, or damage to the trachea and surrounding structures. Immediate assessment of respiratory effort ensures that the airway is patent and the patient is not in respiratory distress. This step is crucial to prevent hypoxia and other serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Teaching the spouse how to assist with transfers and mobility is important for long-term care, but it is not the highest priority at this moment. The focus should be on immediate patient care and assessment.
Choice B reason: Collaborating with physical therapy for gait training is essential for improving the patient's mobility and safety, but it can be scheduled after addressing more urgent needs.
Choice C reason: Monitoring for dysphagia during meals is crucial to prevent aspiration, especially in patients with Parkinson's disease. However, this is a part of ongoing care and not necessarily the immediate priority unless the patient is actively eating.
Choice D reason: Assessing the patient's response to Carbidopa-Levodopa is the highest priority because it directly impacts the patient's overall symptom management. Effective control of Parkinson's symptoms can improve mobility, reduce rigidity, and decrease the risk of complications such as falls and dysphagia.
Choice E reason: Encouraging regular high-calorie, nutrient-dense snacks is important for maintaining the patient's nutritional status, but it is not the immediate priority in comparison to evaluating the effectiveness of medication management.
Correct Answer is C
Explanation
Choice A reason: The red blood cell (RBC) count provided is significantly below the normal range (4,700,000-6,100,000/μL). However, the unit of measure given in the question (48,000/μL) is incorrect for RBCs, so it may not be consistent with the symptoms of fatigue and palpitations. Typically, a low RBC count can contribute to these symptoms, but in this case, the measurement provided is not clear.
Choice B reason: Platelets of 120,000/μL are below the normal range (150,000-400,000/μL). While low platelet counts (thrombocytopenia) can lead to bleeding and bruising, they are not typically associated with symptoms of fatigue and palpitations. This finding is more indicative of a potential bleeding disorder rather than anemia or another condition that would cause the given symptoms.
Choice C reason: Hemoglobin (Hgb) of 6.9g/dL is significantly below the normal range (14-18g/dL) and indicates severe anemia. Anemia is a common cause of fatigue and palpitations because the body has a reduced capacity to carry oxygen to tissues. Low hemoglobin levels can lead to decreased oxygen delivery, resulting in increased fatigue and compensatory palpitations as the heart works harder to circulate oxygen-poor blood.
Choice D reason: White blood cell (WBC) count of 11,000/mm³ is slightly above the normal range (5,000-10,000/mm³) and indicates a mild leukocytosis, which is usually a sign of infection or inflammation. While leukocytosis can cause fatigue if there is an underlying infection, it is not directly associated with palpitations and severe fatigue. The primary concern with fatigue and palpitations lies more with oxygen-carrying capacity, which is affected by hemoglobin levels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.