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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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
Correct Answer is A
Explanation
Choice A Reason:
Increased serum amylase is a key indicator of acute pancreatitis. Amylase is an enzyme produced by the pancreas to help digest carbohydrates. In cases of acute pancreatitis, the pancreas becomes inflamed, leading to the release of amylase into the bloodstream. Elevated levels of serum amylase, typically more than three times the upper limit of normal, are a strong indication of acute pancreatitis. This enzyme level usually rises within a few hours of the onset of pancreatitis and can remain elevated for several days.
Choice B Reason:
Increased serum calcium is not typically associated with acute pancreatitis. In fact, acute pancreatitis can often lead to hypocalcemia (low calcium levels) due to fat saponification in the pancreas, where calcium binds with fatty acids. Therefore, an increase in serum calcium would not be expected in a patient with acute pancreatitis. Monitoring calcium levels is important, but an increase is not a diagnostic marker for this condition.
Choice C Reason:
Decreased WBC (white blood cell count) is not a characteristic finding in acute pancreatitis. On the contrary, acute pancreatitis often leads to an elevated WBC count due to the inflammatory response in the body. Leukocytosis (increased WBC) is a common finding in many inflammatory and infectious conditions, including acute pancreatitis. Therefore, a decreased WBC count would not be expected and does not support the diagnosis of acute pancreatitis.
Choice D Reason:
Decreased serum lipase is incorrect. Similar to amylase, lipase is another enzyme produced by the pancreas, which helps in the digestion of fats. In acute pancreatitis, serum lipase levels also increase significantly, often more than three times the upper limit of normal. Lipase levels tend to rise slightly later than amylase but remain elevated for a longer period, making it a useful marker for diagnosing acute pancreatitis. Therefore, decreased serum lipase would not be expected in this condition.
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