A nurse is caring for a client on a medical-surgical unit.
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. Click to highlight the findings below that the nurse should report to the provider.
Nurses Notes
Oxygen saturation 95%
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
Oxygen saturation 95%
The Correct Answer is ["A","B","C","D","E","F"]
The nurse should report the hoarseness of the client's voice, which could indicate recurrent laryngeal nerve damage, which is a risk associated with thyroid surgery. Tingling around the mouth may suggest hypocalcemia, a common complication after thyroidectomy due to accidental removal or damage to the parathyroid glands. The moderate serosanguinous drainage on the neck dressing could signify bleeding or infection, which requires immediate attention. The noted tremor in both hands and the increase in temperature could be signs of a thyroid storm, a rare but life-threatening condition.
Furthermore, the client's restlessness could be a response to discomfort or could indicate a more serious issue, such as an impending thyrotoxic crisis. Oxygen saturation at 95% is within normal limits postoperatively; however, it should be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Creatinine levels rise in acute kidney injury due to impaired kidney function, as the kidneys are unable to effectively filter creatinine from the blood.
B. BUN (blood urea nitrogen) levels typically increase in dehydration due to reduced kidney perfusion, leading to decreased urine output and increased concentration of waste products in the blood.
C. Specific gravity increases in hypovolemia because urine becomes more concentrated as the body tries to conserve water.
D. Potassium levels may vary depending on the cause of polyuria, but polyuria itself does not necessarily cause hyperkalemia. It can be caused by various factors including diabetes insipidus or diabetes mellitus.
Correct Answer is D
Explanation
A. This statement is unrelated to the client's kidney stones and does not require reporting to the provider.
B. This statement indicates good fluid intake, which is generally beneficial for preventing kidney stones. It does not require reporting.
C. This statement is unrelated to the client's kidney stones and does not require reporting.
D. This statement indicates possible hematuria (blood in the urine) and pain, which could be indicative of a urinary tract issue related to the kidney stones and requires reporting to the provider for further assessment and management.
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