A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery
The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patient's trachea on auscultation. The patient's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action?
A) Encourage the patient to perform deep breathing and coughing exercises hourly.
B) Reposition the patient into a prone or semi-Fowler's position and apply supplementary oxygen by nasal cannula.
C) Activate the emergency response system.
D) Report this finding promptly to the physician and remain with the patient.
Ans: D
Feedback:
In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patient's current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.
You might also like to view...
A patient is admitted to the emergency room after consuming 50 acetaminophen tablets in a suicide attempt. What medication will be administered to counteract the effect of the acetaminophen?
A) Oxymetazoline hydrochloride (Afrin) B) Acetylcysteine (Mucomyst) C) Daptomycin (Cubicin) D) Darbepoetin alfa (Aranesp)
The discussion of the central phenomena or variables of a study, along with the theoretical or conceptual framework of the study, is found in which section of the study?
A) Discussion B) Abstract C) Introduction D) Results
Which of the following are examples of developmental risk factors? Select all that apply
A) A toddler is allowed to crawl in a house that has not been childproofed. B) A machinist works in an environment that exposes him to loud noises. C) A sales executive worries that he won't make his yearly sales quota. D) An elderly woman in a long-term healthcare facility is at high risk for falls. E) A 42-year-old woman is unable to move her left side following a stroke. F) A teenager has difficulty ambulating following multiple fractures from a MVA.
A nurse is caring for a female patient who is scheduled for an abdominal hysterectomy. The nurse obtains the patient's signature on the consent form and then signs the form himself. The nurse's signature indicates that
1. The patient does not have any questions about the surgery. 2. The nurse verified that it was the patient who signed the form. 3. The patient understands the risks of the procedure. 4. The nurse has provided verbal and written information about the surgical procedure.