Twelve hours after a total thyroidectomy, the client develops stridor. Which is the nurse's priority intervention?
a. Reassure the client that the voice change is temporary.
b. Document the finding and assess the client hourly.
c. Hyperextend the client's neck and apply oxygen.
d. Prepare for emergency tracheostomy and call the health care provider.
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. The other choices do not address the emergency situation.
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The treatment of chronic disease does not include
a. A focus on curing the disease process b. Symptom management c. Maximizing the individual's strengths d. Prevention of disabling side effects
The nurse is assessing an elderly client who was diagnosed with GERD for complaints of heartburn at night that is so severe it causes insomnia. After some discussion they decide that the client will:
1. Avoid caffeine at bedtime and sleep with the head of his bed elevated. 2. Substitute a noncaffeinated diet soda before bed in place of tea. 3. Limit food seasonings to garlic, red pepper, and sea salt. 4. Continue hot tea at bedtime and sleep with the foot of his bed elevated.
The assessment of a newborn at 1 hour of age reveals the following: temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate 55 breaths/minute, color pink with acrocyanosis
Based on these clinical findings, the nurse should conclude that: a. The infant is in respiratory distress. b. Measures to warm the infant should be taken. c. The infant is showing signs of cold stress. d. No nursing interventions are necessary.
What is the main function of platelets?
a. to wall off foreign proteins, preventing infection b. to carry nutrients to tissues throughout the body c. to be involved in the recovery process in infection d. to facilitate blood coagulation to control bleeding