A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor, and an increase in swelling of the anterior neck area. What should the nurse do first?

Activate the hospital’s emergency or rapid response system.

Place a heart monitor on the client and observe for dysrhythmias.

Ask the charge nurse to come see the client immediately.

Check the client’s blood pressure and heart rate.

Provide a calm and assuring environment for the client.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Activating the hospital’s emergency or rapid response system is the most appropriate first action in this scenario. The client is exhibiting signs of a potentially life-threatening condition, such as airway obstruction or severe swelling that could compromise breathing. Immediate intervention by a rapid response team can provide the necessary advanced airway management and other critical care measures to stabilize the patient. This action prioritizes the client’s airway, breathing, and circulation, which are the fundamental aspects of emergency care.

Choice B Reason:

Placing a heart monitor on the client and observing for dysrhythmias is important but not the immediate priority in this situation. While monitoring the heart is crucial, the client’s airway and breathing issues take precedence. Addressing the airway obstruction and ensuring adequate breathing should be the first step before focusing on cardiac monitoring.

Choice C Reason:

Asking the charge nurse to come see the client immediately is a reasonable action, but it may delay the necessary urgent intervention. The charge nurse may not have the advanced skills or equipment required to manage a severe airway obstruction. Activating the rapid response system ensures that a team of healthcare professionals with the appropriate expertise and equipment can respond quickly.

Choice D Reason:

Checking the client’s blood pressure and heart rate is a standard nursing assessment, but it is not the immediate priority in this emergency situation. The client’s difficulty breathing and stridor indicate a potential airway obstruction, which requires immediate attention. Ensuring the airway is clear and the client can breathe is more critical than checking vital signs at this moment.

Choice E Reason:

Providing a calm and assuring environment for the client is important for reducing anxiety and stress, but it does not address the immediate life-threatening issue. While maintaining a calm environment is beneficial, the nurse must first ensure that the client’s airway is secure and that they can breathe adequately. This can only be achieved by activating the rapid response system.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Reason:

Monitoring the QT interval is crucial when administering amiodarone because this drug can prolong the QT interval, increasing the risk of torsades de pointes, a potentially life-threatening type of ventricular tachycardia. Regular monitoring helps in early detection and management of this adverse effect, ensuring patient safety.

Title: Choice B Reason:

Heart rate monitoring is essential as amiodarone can cause bradycardia (slow heart rate). Continuous monitoring allows the nurse to detect any significant changes in heart rate and take appropriate actions, such as adjusting the medication dosage or providing interventions to manage bradycardia.

Title: Choice C Reason:

Respiratory rate monitoring is necessary because amiodarone can cause pulmonary toxicity, including interstitial pneumonitis and acute respiratory distress syndrome (ARDS). By keeping track of the respiratory rate, the nurse can identify early signs of respiratory complications and intervene promptly

Title: Choice D Reason:

Heart rhythm monitoring is vital since amiodarone is used to treat arrhythmias. Continuous electrocardiogram (ECG) monitoring helps in assessing the effectiveness of the drug in controlling arrhythmias and detecting any new or worsening arrhythmias that may require immediate attention.

Title: Choice E Reason:

Monitoring urine output is important because amiodarone can affect renal function, especially in patients with pre-existing kidney conditions. Keeping track of urine output helps in assessing renal function and ensuring that the drug is not causing nephrotoxicity

A. He is NPO until the speech-language pathologist performs a swallowing evaluation. B. Be sure to sit him up when you are feeding him to make him feel more natural. C. You may give him a full-liquid diet, but please avoid solid foods until he gets stronger. D. Just be sure to add some thickener in his liquids to prevent choking and aspiration.

Correct Answer is A

Explanation

Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.

This is the most appropriate response. NPO stands for “nil per os,” which means nothing by mouth. After a stroke, it is crucial to assess the patient’s ability to swallow safely to prevent aspiration, which can lead to pneumonia and other complications. A speech-language pathologist is trained to evaluate swallowing function and determine the safest diet for the patient. Until this evaluation is completed, the patient should not consume any food or liquids.

Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.

While sitting the patient up during feeding is important to reduce the risk of aspiration, it is not sufficient on its own. Without a proper swallowing evaluation, feeding the patient could still pose significant risks. Therefore, this choice is not the most appropriate response.

Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.

A full-liquid diet might seem like a safer option, but without a swallowing evaluation, there is still a risk of aspiration. The patient’s ability to handle even liquids needs to be assessed by a professional before any oral intake is allowed.

Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.

Thickening liquids can help manage dysphagia, but this should only be done after a swallowing evaluation has determined the appropriate consistency. Administering thickened liquids without an evaluation could still result in aspiration if the patient has severe swallowing difficulties.

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A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor, and an increase in swelling of the anterior neck area. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client’s nutritional needs. Which response by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.)

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for what?

You are caring for a client in the ED with B/P 254/139 mm Hg. Which of the following actions would you take first?

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client’s nutritional needs. Which response by the nurse is appropriate?

Exhibits You retrieved regular insulin 100 units in 1 ml. How many ml should you administer? Note Enter ONLY the number DO NOT enter the unit(s) of measurement

The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Which symptom will the nurse anticipate in a patient diagnosed with supraventricular tachycardia (SVT) with a non-sustained ventricular response?