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
Inspecting the client's skin near the end of the bathing procedure allows the PN to directly assess the UAP's performance and evaluate the effectiveness of the bed bath. By observing the client's skin, the PN can determine if the UAP has properly cleaned and cared for the client's skin, identified any areas that may have been missed, and ensured that proper hygiene practices have been followed.
B. While verifying with the client that the bath was complete and thorough is important for client satisfaction, it may not provide a comprehensive evaluation of the UAP's performance. Clients may not be aware of all the necessary steps involved in a complete bed bath, so their perception may not accurately reflect the quality of the UAP's work.
C. Requesting the UAP to report and chart when the bath is complete is a useful documentation practice, but it does not provide a direct evaluation of the UAP's performance during the bed bath.
D. Asking another UAP to help the orientee may be helpful for providing guidance and support during the orientation process, but it does not provide a specific evaluation of the UAP's performance in completing the bed bath.
Correct Answer is C
Explanation
When assessing an older client with left-sided heart failure (HF), the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. Left-sided heart failure is characterized by the inability of the left ventricle to effectively pump blood, leading to fluid accumulation in the lungs. Auscultating all lung fields allows the PN to assess for the presence of abnormal lung sounds such as crackles, indicating pulmonary congestion.
In summary, when assessing an older client with left-sided heart failure, the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. This allows for the detection of abnormal lung sounds associated with pulmonary congestion, a hallmark sign of left-sided heart failure.
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