A patient has just arrived on the unit after a thyroidectomy. Which action would the nurse take first?
Check the blood pressure and pulse.
Observe the dressing for bleeding.
Support the patient's head with pillows.
Assess the patient's respiratory effort.
The Correct Answer is D
Choice A reason: Checking the blood pressure and pulse is important as part of the routine monitoring of vital signs to assess the patient's hemodynamic status. However, it is not the first action to take following a thyroidectomy. Ensuring that the patient's airway is clear and that there is no respiratory distress is paramount, as any compromise in the airway can lead to life-threatening situations. Blood pressure and pulse can be checked after confirming the patient is breathing properly.
Choice B reason: Observing the dressing for bleeding is also important because post-operative bleeding can be a serious concern. However, this action should follow the assessment of the patient's airway. If the patient is experiencing respiratory distress, addressing the airway takes precedence. Once it is confirmed that the airway is clear, then the nurse can check for bleeding and ensure the dressing is intact.
Choice C reason: Supporting the patient's head with pillows is beneficial for comfort and proper positioning, especially to avoid strain on the surgical site. However, positioning should not be the first priority. Ensuring that the patient's airway is clear and that there is no respiratory compromise is the most urgent concern. Proper positioning can be done after confirming that the patient is breathing adequately.
Choice D reason: Assessing the patient's respiratory effort is the first and most critical action. Following a thyroidectomy, there is a risk of respiratory complications due to potential swelling, bleeding, or damage to the trachea and surrounding structures. Immediate assessment of respiratory effort ensures that the airway is patent and the patient is not in respiratory distress. This step is crucial to prevent hypoxia and other serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
Choice A reason: A tongue blade is not typically necessary for a patient with status epilepticus. It is more commonly used for oral care or to check the throat, but it is not essential in this context.
Choice B reason: A urinary catheter is not necessary unless the patient has specific urinary retention issues or requires accurate measurement of urine output. It is not standard equipment for managing status epilepticus.
Choice C reason: A nasogastric tube is not typically required for status epilepticus unless there are specific gastrointestinal issues that need to be addressed. It is not standard equipment for managing status epilepticus.
Choice D reason: A suction set up is essential for a patient with status epilepticus to manage potential airway secretions and prevent aspiration. It ensures that the airway remains clear and reduces the risk of complications.
Choice E reason: An oxygen mask is crucial for a patient with status epilepticus to ensure adequate oxygenation. It helps maintain oxygen levels and supports respiratory function, especially if the patient experiences respiratory distress.
Choice F reason: Side-rail pads are important for patient safety, particularly for a patient with status epilepticus who may be at risk of falls or injury during seizures. They provide a protective barrier and help prevent accidental injury.
Correct Answer is B
Explanation
Choice A reason: Asking the HCP to change the medication from heparin to enoxaparin (Lovenox) would not be the most appropriate action for a patient diagnosed with heparin-induced thrombocytopenia (HIT). Enoxaparin, like heparin, is a low molecular weight heparin and can still cause HIT. Therefore, this action does not address the immediate need to stop the heparin infusion to prevent further reduction in platelet levels and manage the HIT effectively.
Choice B reason: Discontinuing the heparin infusion is the correct action for a nurse to take first when a patient is diagnosed with heparin-induced thrombocytopenia (HIT). The primary step in managing HIT is to stop all forms of heparin to prevent further platelet activation and decrease in platelet count. Discontinuing heparin helps to prevent thromboembolic complications associated with HIT. Once heparin is discontinued, the healthcare provider can evaluate alternative anticoagulation therapies that do not cross-react with heparin, such as direct thrombin inhibitors.
Choice C reason: Administering prescribed warfarin (Coumadin) is not appropriate at this stage for a patient diagnosed with heparin-induced thrombocytopenia (HIT). Warfarin can initially lead to a hypercoagulable state, which increases the risk of thrombosis in patients with HIT. The immediate priority is to discontinue heparin, and warfarin should only be considered once platelet counts have recovered and the acute HIT has been managed.
Choice D reason: Preparing for platelet transfusion is not the first action to take for managing heparin-induced thrombocytopenia (HIT). Platelet transfusions are generally avoided in HIT as they can potentially worsen the thrombotic risk. The primary action should be to discontinue heparin and consider alternative anticoagulation therapies. Platelet transfusions may be reserved for cases where there is significant bleeding or invasive procedures are planned.
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