A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
a. Reassure the client that the voice change is temporary.
b. Document the finding and assess the client hourly.
c. Place the client in high-Fowler's position and apply oxygen.
d. Contact the provider and prepare for intubation.
ANS: D
Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open.
You might also like to view...
Disorders in children that involve problems with expression, receiving messages, word pronunciation, and stuttering are disorders of
1. conduct. 2. learning. 3. communication. 4. developmental.
A substance-dependent pregnant woman is admitted with the diagnosis of possible placental abruption. Which substance would most likely cause this effect during pregnancy?
a. Alcohol c. Marijuana b. Cocaine d. Phencyclidine (PCP)
The nurse determines that a client has a Braden Scale score of 9 . Which is the nurse's best intervention related to this assessment?
a. Document the finding per protocol. b. Reassess the client in 3 days. c. Increase the client's fluid intake. d. Consult with the health care provider.
The nursing profession uses the term _____________ when attempting to explain apparent relationships between observed behaviors and their effects on a client's health
Fill in the blank(s) with correct word