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 ["31"]
Explanation
Step 1: Calculate the total infusion time in minutes.
8 hours × 60 minutes/hour = 480 minutes
Result at each step = 480 minutes
Step 2: Calculate the total number of drops to be infused.
1,000 mL × 15 drops/mL = 15,000 drops
Result at each step = 15,000 drops
Step 3: Calculate the infusion rate in drops per minute.
15,000 drops ÷ 480 minutes = 31.25 drops/minute
Result at each step = 31.25 drops/minute
Step 4: Round to the nearest whole number if necessary.
31.25 drops/minute rounds to 31 drops/minute
Result at each step = 31 drops/minute
Therefore, the nurse should run the IV infusion at a rate of 31 drops per minute.
Correct Answer is A
Explanation
Choice A Reason:
Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.
Choice B Reason:
A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.
Choice C Reason:
Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.
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