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 D

Explanation

D. A thrill is a palpable vibration or buzzing sensation felt over the graft site, caused by turbulent blood flow. In the context of an arteriovenous graft, a palpable thrill is typically considered a positive finding, indicating adequate circulation through the graft. It suggests that blood is flowing smoothly from the arterial to the venous side of the graft.
A. The presence of a bruit is typically considered a positive finding, indicating adequate blood flow through the graft. Therefore, the absence of a bruit may indicate inadequate circulation or a potential complication such as graft occlusion or stenosis.
B. Normal blood pressure is not a specific indicator of the adequacy of circulation through an arteriovenous graft.
C. A dilated appearance of the graft may suggest venous hypertension or increased pressure within the graft. While this could indicate adequate blood flow, it may also suggest problems such as venous stenosis or thrombosis, which can impede circulation through the graft.

A. Disoriented to person, place, and time B. Oxygen saturation 96% at 2 L/min via nasal cannula C. Hct 45% D. Butterfly rash E. Blood pressure 100/50 mm Hg

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

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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

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Correct Answer is D

Explanation

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

Explanation

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