A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

Check for bleeding on the dressing at the back of the client’s neck.

Ensure that acetylcysteine IV is readily available.

Place the client in a side-lying position.

Check the client for asterixis.

Answer and Explanation

The Correct Answer is A

Choice A: Check for bleeding on the dressing at the back of the client’s neck. This is an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy, which is a surgical removal of part of the thyroid gland. The nurse should check for bleeding on the dressing at the back of the client’s neck because this is where blood can pool and go unnoticed. Bleeding can cause hematoma, compression of the airway, and respiratory distress.

Choice B: Ensure that acetylcysteine IV is readily available. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Acetylcysteine IV is an antidote for acetaminophen overdose, which can cause liver damage, but it is not related to thyroid surgery.

Choice C: Place the client in a side-lying position. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. The nurse should place the client in a semi-Fowler’s position, which is a position with the head of the bed elevated to 30 to 45 degrees. This position can facilitate breathing, reduce edema, and prevent aspiration.

Choice D: Check the client for asterixis. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Asterixis is a sign of hepatic encephalopathy, which is a condition caused by liver failure, but it is not related to thyroid surgery.

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Correct Answer is D

Explanation

Choice A: Rapid pulse. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause rapid pulse due to increased sympathetic nervous system activity and decreased cardiac output.

Choice B: Clammy skin. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia. Hypoglycemia can cause clammy skin due to increased sweating and vasoconstriction.

Choice C: Choice C: Confusion is commonly found in HHS rather than DKA.

Choice D: Polydipsia. This is a finding that indicates that the client is experiencing DKA due to the high level of glucose in the blood. Hyperglycemia in DKA can cause polydipsia, which is excessive thirst, due to osmotic diuresis and dehydration.

A. Docusate B. A corticosteroid medication C. Aspirin D. A bowel cathartic medication

Correct Answer is B

Explanation

Choice A: Docusate. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Docusate is a stool softener that can prevent constipation and straining, but it is not indicated for ulcerative colitis.

Choice B: A corticosteroid medication. This is a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis, which is a chronic inﬂammatory bowel disease that causes ulcers and inﬂammation in the colon and rectum. A corticosteroid medication, such as prednisone, can reduce inﬂammation, suppress the immune system, and relieve symptoms such as diarrhea, bleeding, and pain.

Choice C: Aspirin. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Aspirin is a nonsteroidal anti-inﬂammatory drug (NSAID) that can relieve pain and inﬂammation, but it can also irritate the gastrointestinal mucosa and worsen ulcerative colitis.

Choice D: A bowel cathartic medication. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. A bowel cathartic medication, such as bisacodyl, can stimulate bowel movements and cleanse the colon, but it can also cause dehydration, electrolyte imbalance, and aggravate ulcerative colitis.

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A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

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