While caring for a client one day following a thyroidectomy, the practical nurse (PN) notes that the client's voice is hoarse. What action should the PN take?
Notify the unit charge nurse of the finding.
Administer humidified oxygen per nasal cannula.
Obtain a cup of ice chips for the client.
Ensure that the drainage device is compressed.
The Correct Answer is A
Hoarseness or voice changes after thyroidectomy can be indicative of injury or irritation to the recurrent laryngeal nerve, which is responsible for controlling the vocal cords. This is a potential complication of the surgery and should be reported to the charge nurse or healthcare provider for further evaluation and management.
B. Administer humidified oxygen per nasal cannula: This option is not appropriate for addressing hoarseness in a client following a thyroidectomy. Hoarseness after a thyroidectomy is typically related to vocal cord injury or irritation, and providing humidified oxygen would not directly address this issue. It is important to notify the charge nurse or healthcare provider for further evaluation and management.
C. Obtain a cup of ice chips for the client: Providing ice chips is not the appropriate action for hoarseness following a thyroidectomy. Ice chips are typically used to provide hydration and comfort to clients, but they do not directly address the underlying cause of hoarseness, which in this case may be vocal cord injury or irritation. It is important to notify the charge nurse or healthcare provider for appropriate evaluation and management.
D. Ensure that the drainage device is compressed: While ensuring proper compression of a drainage device is important for preventing complications such as bleeding or infection, it is not directly related to the client's hoarseness. Hoarseness after a thyroidectomy is more likely related to vocal cord injury or irritation, and notifying the charge nurse or healthcare provider is necessary for further assessment and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
Correct Answer is C
Explanation
This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic effect. However, this also means that the client is at a higher risk of developing toxicity or side effects from the medication.
The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inflammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.
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