While assessing a patient who has just arrived from the Post Anesthesia Care Unit (PACU), the nurse hears stridor. What is the first action the nurse should take?
Ask the patient to perform deep-breathing exercises.
Administer prescribed albuterol nebulizer therapy.
Call a Rapid Response.
Contact the primary health care provider and prepare for intubation.
The Correct Answer is D
Choice A rationale:
Incorrect. Deep-breathing exercises could potentially worsen stridor. Stridor is a high-pitched, wheezing sound caused by a partial obstruction of the upper airway. Deep breathing can increase airflow through the narrowed airway, making the stridor more pronounced and potentially worsening the obstruction. In severe cases, it could lead to complete airway obstruction and respiratory distress.
Risk of aggravation: Deep-breathing exercises could aggravate the underlying cause of stridor, such as laryngeal edema or vocal cord dysfunction, by increasing inflammation or muscle tension in the airway.
Delay in definitive treatment: Focusing on deep-breathing exercises might delay more definitive interventions, such as intubation, which might be necessary to secure the airway and prevent respiratory failure.
Choice B rationale:
Incorrect. While albuterol nebulizer therapy can be helpful for bronchospasm, it is not the first-line treatment for stridor. Stridor is typically caused by an upper airway obstruction, and albuterol primarily targets the lower airways (bronchioles).
Limited effectiveness: Albuterol might not be effective in reducing stridor caused by upper airway obstruction, as it does not directly address the narrowing of the airway.
Potential for adverse effects: Albuterol can cause tachycardia, tremors, and anxiety, which could further complicate the patient's condition.
Choice C rationale:
Not the most immediate action. While calling a Rapid Response might be necessary if the patient's condition deteriorates, the first priority is to secure the airway and ensure adequate ventilation.
Time-consuming: Activating a Rapid Response team can take several minutes, and the patient's condition might not allow for that delay.
Choice D rationale:
Prioritizes airway management: Intubation is the most effective way to secure the airway and ensure adequate ventilation in a patient with stridor. It bypasses the obstruction and allows for controlled delivery of oxygen and ventilation.
Addresses potential for deterioration: Stridor can rapidly progress to complete airway obstruction, so prompt preparation for intubation is crucial to prevent respiratory failure.
Involves the primary healthcare provider: Consulting the primary health care provider ensures timely decision-making, appropriate medication administration (such as sedatives or paralytics for intubation), and coordination of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While providing information about post-operative care and pain management is important, it may not directly address the patient's underlying anxiety or encourage them to express their concerns.
It could be perceived as dismissive of their feelings or as an attempt to control the conversation. It focuses on the future rather than the patient's present experience.
Choice B rationale:
This response, while intended to be reassuring, may minimize the patient's individual experience and feelings. It could make the patient feel as though their concerns are not being taken seriously.
It implies that anxiety is a normal and expected reaction, which may discourage the patient from sharing their specific worries.
Choice C rationale:
This response is open-ended and invites the patient to share their thoughts and feelings.
It demonstrates active listening and encourages the patient to take an active role in the conversation.
It allows the nurse to assess the patient's understanding of the surgery and to address any misconceptions or concerns. It conveys a sense of empathy and understanding, which can help to build trust and rapport with the patient.
Choice D rationale:
While offering to explain the procedure may be helpful, it may not be what the patient needs at the moment. It could overwhelm the patient with information, particularly if they are already feeling anxious.
It could shift the focus away from the patient's emotional needs and onto the technical aspects of the surgery.
Correct Answer is D
Explanation
Choice A rationale:
While working in a facility affiliated with a medical or nursing school can offer opportunities for professional development and collaboration, it is not the most important factor to consider when choosing a new job.
Affiliation with a school does not guarantee a positive work environment, strong nursing leadership, or a commitment to quality patient care, which are all hallmarks of Magnet hospitals.
It's essential to consider other factors that directly impact job satisfaction, patient outcomes, and overall nursing excellence.
Choice B rationale:
Having the latest technology can be beneficial, but it does not ensure a supportive work environment or a high standard of nursing care.
Technology is only one aspect of a hospital's operations, and it should not be the primary focus when making a career decision. It's crucial to prioritize factors that directly influence the quality of nursing practice and patient outcomes.
Choice C rationale:
Inquiring about nurse-client ratios is important, as it can provide insight into the workload and staffing levels at a hospital. However, it's not the most comprehensive indicator of a hospital's commitment to nursing excellence.
Magnet status, in contrast, signifies a broader commitment to quality nursing care, professional development, and positive work environments.
Choice D rationale:
Magnet status is a prestigious designation awarded by the American Nurses Credentialing Center (ANCC) to hospitals that demonstrate excellence in nursing care, leadership, and innovation.
Magnet hospitals are known for:
Attracting and retaining highly qualified nurses Fostering a culture of collaboration and teamwork Investing in professional development and growth
Promoting evidence-based practice and quality improvement Demonstrating outstanding patient outcomes
Seeking employment at a Magnet hospital is strongly recommended for nurses who prioritize professional growth, job satisfaction, and the delivery of exceptional patient care.
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