A nurse is caring for a patient 4 hours after a thyroidectomy. Which assessment finding requires immediate intervention?

Neck swelling and stridor

Oxygen saturation of 95%

Pain at the incision site

Hoarseness

Answer and Explanation

The Correct Answer is A

A. Neck swelling and stridor: Neck swelling with stridor indicates airway compromise, likely due to postoperative hemorrhage or hematoma compressing the trachea. This is a life-threatening emergency after thyroidectomy and requires immediate intervention to secure the airway and prevent respiratory arrest. Rapid assessment and notification of the surgeon are critical.

B. Oxygen saturation of 95%: An oxygen saturation of 95% is slightly below normal but not immediately life-threatening. It should be monitored closely, but it does not require the same urgent response as signs of airway obstruction.

C. Pain at the incision site: Pain is expected after thyroid surgery and is typically managed with analgesics. While important for patient comfort, it does not indicate a life-threatening complication requiring immediate action.

D. Hoarseness: Temporary hoarseness is common after thyroidectomy due to laryngeal nerve irritation. It is usually transient and not an immediate threat to airway patency, although persistent or worsening hoarseness should be monitored.

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Correct Answer is D

Explanation

A. Confirm that the patient's consent form is signed and in the chart: Ensuring informed consent is critical for legal and ethical reasons, but it does not directly prevent immediate life-threatening complications during transport of an intubated patient.

B. Notify the surgical team of the patient's arrival time: Communicating with the surgical team is important for workflow and preparedness, but it does not directly safeguard the patient’s airway or oxygenation during transport.

C. Document the time the patient left the unit and who accompanied them: Accurate documentation is essential for accountability and continuity of care, yet it does not actively prevent physiologic compromise during transport.

D. Ensure that portable oxygen and suction equipment are functioning and available: Maintaining a patent airway and adequate oxygenation is the highest priority for an intubated patient. Portable oxygen and suction are critical in case of accidental extubation, obstruction, or respiratory compromise during transport, making this the most important safety measure

A. Sitting in the tripod position B. 02 saturation of 91% C. Respiratory rate has decreased from 30 to 10 breaths/min D. Bilateral lung crackles

Correct Answer is C

Explanation

A. Sitting in the tripod position: Tripod positioning is a common compensatory mechanism in patients with COPD to maximize diaphragmatic expansion and ease breathing. While it indicates respiratory distress, it is an expected adaptive behavior and not immediately life-threatening.

B. O₂ saturation of 91%: An oxygen saturation of 91% is slightly below normal and should be monitored. In COPD patients, target saturations are often 88–92%, so this finding alone may not require urgent intervention if the patient is otherwise stable.

C. Respiratory rate has decreased from 30 to 10 breaths/min: A sudden drop in respiratory rate in a patient previously tachypneic is highly concerning, as it suggests impending respiratory failure or fatigue of the respiratory muscles. This change indicates inadequate ventilation and CO₂ retention, requiring immediate notification to the healthcare provider for urgent intervention.

D. Bilateral lung crackles: Crackles may indicate fluid overload, infection, or pulmonary edema, which are important to monitor and treat. However, in acute respiratory distress, a decreasing respiratory rate represents a more immediate threat to oxygenation and ventilation, making it the highest priority to report.

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A nurse is caring for a patient 4 hours after a thyroidectomy. Which assessment finding requires immediate intervention?

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Naxlex Comprehensive Predictor Exams

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