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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.
When a client is admitted with a stroke, especially one affecting the left side, there is a significant risk of dysphagia, or difficulty swallowing. This can lead to choking and aspiration, which can cause pneumonia and other complications. Therefore, it is crucial to keep the client NPO (nothing by mouth) until a speech-language pathologist can perform a thorough swallowing evaluation. This ensures that the client can safely swallow without the risk of aspiration. The speech-language pathologist will assess the client’s ability to swallow different textures and consistencies of food and liquids and provide recommendations for safe feeding.
Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.
While sitting the client up during feeding is a good practice to reduce the risk of aspiration, it is not sufficient on its own for a client who has just had a stroke. Without a proper swallowing evaluation, feeding the client could still pose a significant risk. 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 it still poses a risk of aspiration if the client has dysphagia. Without a swallowing evaluation, it is not safe to assume that the client can handle even a full-liquid diet. Therefore, this choice is not appropriate.
Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.
Adding thickener to liquids can help some clients with dysphagia, but it is not a one-size-fits-all solution. The appropriate consistency of liquids should be determined by a speech-language pathologist after a swallowing evaluation. Therefore, this choice is not appropriate without a prior assessment.
Correct Answer is D
Explanation
Choice A Reason:
Malfunction of the alarm button is unlikely to be the cause of increased peak airway pressure. The alarm is designed to alert the nurse to a problem with the ventilator or the patient’s airway, not to malfunction itself. Therefore, this is not the first thing the nurse should assess.
Choice B Reason:
A cut or slice in the tubing from the ventilator could cause a loss of pressure or air leak, but it would not typically result in increased peak airway pressure. Instead, it would likely cause a decrease in pressure and potentially trigger a different alarm.
Choice C Reason:
Higher than normal endotracheal cuff pressure can contribute to increased peak airway pressure. However, it is not the most immediate concern compared to a kink in the tubing, which can completely obstruct airflow and rapidly compromise the patient’s ventilation.
Choice D Reason:
A kink in the ventilator tubing is a common and immediate cause of increased peak airway pressure. It obstructs the flow of air, leading to a buildup of pressure in the system. This is the first thing the nurse should assess and correct to ensure the patient is receiving adequate ventilation.
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