A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Neck stiffness

Hoarseness

Moderate serosanguineous drainage

Muscle twitching

Answer and Explanation

The Correct Answer is D

Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A.   Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B.   Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C.   Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D.   Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

Alterations in level of consciousness is an indicator that the client is in septic shock due to systemic spread of the urinary tract infection

Hematocrit level is normal. Changes in hematocrit levels are not expected in UTI unless the client has hematuria.

A butterfly rash is commonly seen in autoimmune conditions like lupus.

The decrease in oxygen requirements indicates improvement in level of distress and hence improving sepsis

A drop in the systolic blood pressure may indicate that the client is going into septic shock

A. Increase the room temperature. B. Cleanse the client's wounds. C. Administer analgesic medication. D. Start an IV with a large-bore needle.

Correct Answer is D

Explanation

D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention

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A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?

Correct Answer is D

Explanation

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