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Question 1
A post-operative patient develops stridor and increasing respiratory distress 6 hours after a total thyroidectomy. What is the nurse's priority action?
Answer: Notify the surgeon immediately and prepare for emergency airway management, as this indicates laryngeal edema or hematoma compressing the trachea, which is a life-threatening complication.
Question 2
A patient with COPD is admitted with an exacerbation. The nurse notes an oxygen saturation of 88% on room air. What is the priority oxygen delivery target for this patient?
Answer: Maintain oxygen saturation between 88–92% to avoid suppressing the hypoxic drive, which COPD patients rely on for respiratory stimulus.
Question 3
A patient returns from bronchoscopy and requests a drink of water. What must the nurse assess before allowing oral intake?
Answer: The nurse must assess the return of the gag reflex, as the throat is anesthetized during bronchoscopy and aspiration risk is high until the reflex returns.
Question 4
A patient with a pneumothorax has a chest tube in place. The nurse notices the water-seal chamber has stopped fluctuating (tidaling). What does this most likely indicate?
Answer: Cessation of tidaling most likely indicates that the lung has fully re-expanded, though it may also indicate a kinked or obstructed chest tube, which must be ruled out.
Question 5
Which assessment finding in a patient with a pulmonary embolism requires the nurse's most immediate intervention?
Answer: Sudden onset of severe hypoxia with oxygen saturation below 90%, tachycardia, and hypotension indicates a massive PE causing hemodynamic instability, requiring immediate emergency response.