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.
Place the emergency cart at the bedside.
The Correct Answer is A
Choice A reason: The first priority in this situation is to ensure the client’s airway is secure. Difficulty breathing and stridor indicate a potential airway obstruction, which can be life-threatening. Activating the hospital’s emergency or rapid response system ensures that the client receives immediate medical attention from a team equipped to handle such emergencies. This step is crucial to prevent respiratory arrest and other complications.
Choice B reason: While placing a heart monitor on the client and observing for dysrhythmias is important, it is not the immediate priority in this scenario. The client’s airway and breathing take precedence over monitoring heart rhythms. Once the airway is secured and breathing is stabilized, then monitoring for dysrhythmias can be considered.
Choice C reason: Asking the charge nurse to come see the client immediately is a reasonable action, but it is not the most effective first step. The charge nurse may not have the necessary equipment or expertise to handle an acute airway obstruction. Activating the emergency or rapid response system ensures that a specialized team responds quickly.
Choice D reason: Checking the client’s blood pressure and heart rate is important for overall assessment, but it is not the immediate priority when there is a potential airway obstruction. Ensuring the client can breathe is the most critical action. Vital signs can be checked once the airway is secured.
Choice E reason: Providing a calm and assuring environment for the client is beneficial for reducing anxiety, but it does not address the immediate threat to the client’s airway. While maintaining a calm environment is important, the nurse must first ensure the client’s airway is open and breathing is adequate.
Choice F reason: Placing the emergency cart at the bedside is a preparatory step that can be useful, but it is not the first action to take. The nurse should first activate the emergency or rapid response system to get immediate help. The emergency cart can be brought to the bedside by the responding team.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Assess the client’s oxygen saturation and, if normal, turn off the oxygen. This option is not ideal because turning off the oxygen completely can lead to a rapid drop in oxygen saturation levels, especially in patients who require continuous oxygen therapy. Monitoring oxygen saturation is crucial, but turning off the oxygen is not recommended unless specifically advised by a healthcare provider. Normal oxygen saturation levels typically range from 95% to 100%1. If the levels drop below 90%, it can lead to hypoxemia, which can cause serious complications.
Choice B Reason:
Have the client lift the mask off the face when taking bites of food. This option is also not ideal because it can be cumbersome for the client and may lead to inconsistent oxygen delivery. The Venturi mask is designed to provide a precise concentration of oxygen, and lifting it off repeatedly can disrupt this consistency. Additionally, it can be uncomfortable and impractical for the client to manage the mask while eating.
Choice C Reason:
Turn the oxygen off while the client eats the meal and then restart it. This option is not recommended for similar reasons as Choice A. Turning off the oxygen can lead to a significant drop in oxygen saturation levels, which can be dangerous for the client. Continuous oxygen therapy is essential for maintaining adequate oxygen levels in patients who require it. Interrupting this therapy, even temporarily, can have adverse effects on the client’s health.
Choice D Reason:
Determine if the client can switch to a nasal cannula during the meal. This is the best option because a nasal cannula allows the client to receive continuous oxygen while eating. The nasal cannula is less obtrusive and more comfortable for the client, enabling them to eat without significant interruption to their oxygen therapy. Nasal cannulas are commonly used for patients who need supplemental oxygen but also need to perform activities such as eating and talking. This approach ensures that the client maintains adequate oxygen levels while having their meal.
Correct Answer is D
Explanation
Choice A: Periodic Nystagmus
Nystagmus, which is characterized by involuntary eye movements, can be a symptom of various neurological conditions, including bacterial meningitis. However, it is not typically an immediate concern compared to other symptoms. Nystagmus indicates potential issues with the brainstem or cerebellum, but it does not directly threaten the patient’s life or indicate a rapid deterioration in condition. Therefore, while it is important to monitor, it is not the most urgent finding.
Choice B: Severe Unrelenting Headaches
Severe headaches are a common symptom of bacterial meningitis due to the inflammation of the meninges. While they are extremely painful and distressing for the patient, they are not as immediately life-threatening as a decreased level of consciousness. Headaches indicate increased intracranial pressure, which is serious, but the priority is to address symptoms that indicate a more rapid decline in neurological function.
Choice C: Photophobia During the Day
Photophobia, or sensitivity to light, is another common symptom of meningitis. It results from the irritation of the meninges and is often accompanied by headaches. While photophobia can be very uncomfortable and indicative of meningitis, it is not an immediate concern compared to a decreased level of consciousness. Photophobia does not directly indicate a life-threatening situation.
Choice D: Decreased Level of Consciousness
A decreased level of consciousness is the most immediate concern for a nurse caring for a patient with bacterial meningitis. This symptom indicates a significant and potentially rapid decline in the patient’s neurological status. It can be a sign of increased intracranial pressure, brain swelling, or other severe complications. Immediate medical intervention is required to prevent further deterioration and potential fatality. Monitoring and addressing changes in consciousness are critical in managing bacterial meningitis effectively.
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