A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor, and an increase in swelling of the anterior neck area. What should the nurse do first?
Activate the hospital’s emergency or rapid response system.
Place a heart monitor on the client and observe for dysrhythmias.
Ask the charge nurse to come see the client immediately.
Check the client’s blood pressure and heart rate.
Provide a calm and assuring environment for the client.
Place the emergency cart at the bedside.
The Correct Answer is A
Choice A reason: The first priority in this situation is to ensure the client’s airway is secure. Difficulty breathing and stridor indicate a potential airway obstruction, which can be life-threatening. Activating the hospital’s emergency or rapid response system ensures that the client receives immediate medical attention from a team equipped to handle such emergencies. This step is crucial to prevent respiratory arrest and other complications.
Choice B reason: While placing a heart monitor on the client and observing for dysrhythmias is important, it is not the immediate priority in this scenario. The client’s airway and breathing take precedence over monitoring heart rhythms. Once the airway is secured and breathing is stabilized, then monitoring for dysrhythmias can be considered.
Choice C reason: Asking the charge nurse to come see the client immediately is a reasonable action, but it is not the most effective first step. The charge nurse may not have the necessary equipment or expertise to handle an acute airway obstruction. Activating the emergency or rapid response system ensures that a specialized team responds quickly.
Choice D reason: Checking the client’s blood pressure and heart rate is important for overall assessment, but it is not the immediate priority when there is a potential airway obstruction. Ensuring the client can breathe is the most critical action. Vital signs can be checked once the airway is secured.
Choice E reason: Providing a calm and assuring environment for the client is beneficial for reducing anxiety, but it does not address the immediate threat to the client’s airway. While maintaining a calm environment is important, the nurse must first ensure the client’s airway is open and breathing is adequate.
Choice F reason: Placing the emergency cart at the bedside is a preparatory step that can be useful, but it is not the first action to take. The nurse should first activate the emergency or rapid response system to get immediate help. The emergency cart can be brought to the bedside by the responding team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A Reason:
Administering 0.45% NS (normal saline) at 50 mL/h is not appropriate for a client with SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion). This solution is hypotonic and can exacerbate the condition by increasing water retention and worsening hyponatremia. Therefore, this choice is not included in the plan of care.
Choice B Reason:
Obtaining daily weight is crucial for monitoring fluid balance in clients with SIADH. Daily weights help detect fluid retention or loss, which is essential for managing the condition. Accurate weight measurements can indicate changes in fluid status and guide adjustments in treatment.
Choice C Reason:
Maintaining seizure precautions is vital for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if seizures occur.
Choice D Reason:
Administering 3% saline as ordered is appropriate for treating severe hyponatremia in clients with SIADH. Hypertonic saline helps increase serum sodium levels, which is critical for correcting the electrolyte imbalance. This intervention should be closely monitored to avoid rapid changes in sodium levels.
Choice E Reason:
Encouraging fluid intake is not appropriate for clients with SIADH. The condition is characterized by excessive water retention, and increasing fluid intake can worsen hyponatremia. Instead, fluid restriction is typically recommended to manage the condition effectively.
Correct Answer is C
Explanation
Choice A: Severe Hypertension
Severe hypertension can be a sign of increased intracranial pressure (ICP), but it is not typically the earliest sign. Hypertension often occurs as a compensatory mechanism to maintain cerebral perfusion pressure. While it is a significant finding, it usually follows other more immediate signs of increased ICP.
Choice B: Dilated and Nonreactive Pupils
Dilated and nonreactive pupils are a late sign of increased ICP and indicate severe brainstem compression. This finding suggests that the pressure has reached a critical level, leading to brain herniation. It is a very serious sign but not the earliest indicator of increasing ICP.
Choice C: Decreased Level of Consciousness
A decreased level of consciousness is often the earliest and most sensitive indicator of increasing ICP. Changes in consciousness can range from confusion and lethargy to complete unresponsiveness. This symptom reflects the brain’s response to increased pressure and reduced cerebral perfusion, making it a critical early sign that requires immediate attention.
Choice D: Projectile Vomiting
Projectile vomiting can occur with increased ICP due to pressure on the vomiting centers in the brainstem. However, it is not typically the earliest sign. Vomiting often accompanies other symptoms such as headache and changes in consciousness.
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