A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
Loose tracheal secretions
Hypoactive bowel sounds
High-pitched sound on inspiration
Client report of pain at the incision
The Correct Answer is C
Choice A reason:
Loose tracheal secretions are incorrect. While this could lead to airway issues if not managed, it's not as urgent as stridor.
Choice B reason:
Hypoactive bowel sounds are incorrect. Bowel sounds can be affected by anaesthesia and the surgical procedure, but they are not as immediately critical as airway issues.
Choice C reason:
High-pitched sound on inspiration. A high-pitched sound on inspiration, also known as stridor, can indicate a potential issue with the airway or breathing. Stridor can occur due to narrowing or obstruction of the upper airway, which can be particularly concerning after a thyroidectomy. It could suggest edema, bleeding, or damage to the laryngeal nerves, which are critical for vocal cord function and airway control. Stridor could potentially lead to airway compromise, making it a priority to report to the provider for immediate evaluation and intervention.
Choice D reason:
Client report of pain at the incision is incorrect. Pain management is important, but it's not an immediate threat to the client's airway or overall condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Increased potassium level is incorrect. Valsartan does not typically cause an increase in potassium levels.
Choice B Reason:
Decreased urinary output is incorrect. Valsartan is not directly associated with changes in urinary output.
Choice C Reason:
Increased heart rate is incorrect. Valsartan generally does not lead to an increased heart rate; it is more likely to help regulate heart rate and reduce strain on the heart.
Choice D Reason:
Decreased blood pressure is correct. Valsartan is an angiotensin II receptor blocker (ARB) commonly used to treat conditions such as heart failure and hypertension. One of its primary effects is to dilate blood vessels and lower blood pressure. Therefore, a decreased blood pressure would indicate that the medication is effective in achieving its therapeutic goal of reducing the workload on the heart and improving circulation.
Correct Answer is A
Explanation
Choice A reason:
Initiating a continuous IV insulin infusion is the first priority. The priority intervention for a client in diabetic ketoacidosis (DKA) is to normalize blood glucose levels and reverse the ketoacidosis. Initiating a continuous IV insulin infusion is essential to rapidly lower the elevated blood glucose levels and counteract the metabolic acidosis associated with DKA.
Choice B reason:
Beginning a bicarbonate continuous IV infusion is generally not the priority in DKA management. While metabolic acidosis is a concern in DKA, insulin therapy and fluid resuscitation are typically the initial focus of treatment.
Choice C reason:
Checking potassium levels is important since potassium imbalances are common in DKA. However, while this is important, it is not the first priority. It's important to ensure that insulin therapy has been initiated before addressing potassium levels.
Choice D reason:
Administering 0.9% sodium chloride (normal saline) is a crucial part of DKA treatment but it is not the first priority as it helps correct dehydration and electrolyte imbalances. However, starting insulin therapy to address the underlying metabolic issue takes precedence.
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