A nurse is caring for a client who is to undergo a subtotal thyroidectomy. Which of the following items should the nurse place at the client’s bedside?
Thoracotomy set
Vacuum assisted wound device
Tracheostomy kit
Tuning fork
The Correct Answer is C
Rationale:
A. Thoracotomy set: A thoracotomy set is used for emergency chest procedures, such as to relieve a pneumothorax or drain the pleural space. It is not relevant to a thyroidectomy, which involves the neck and airway rather than the thoracic cavity.
B. Vacuum assisted wound device: A vacuum-assisted wound device is used for chronic or large open wounds requiring negative pressure therapy. It is not indicated for fresh surgical incisions or preventive airway management following thyroid surgery.
C. Tracheostomy kit: A tracheostomy kit should be readily available at the bedside following thyroid surgery because of the risk of airway obstruction from swelling, bleeding, or damage to the recurrent laryngeal nerve. Immediate airway access may be needed in case of respiratory distress.
D. Tuning fork: A tuning fork is used in auditory and vibration assessments, such as during Rinne and Weber tests. It has no relevance to the immediate post-operative care of a client undergoing a thyroidectomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Calculation:
Total volume to be infused = 500 mL.
- Convert the infusion time from hours to minutes.
Infusion time = 4 hr × 60 min/hr
= 240 min.
Drop factor = 15 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 15 gtt/mL) / 240 min
= 7500 gtt / 240 min
= 31.25 gtt/min.
Rounded to the nearest whole number:
= 31 gtt/min.
Correct Answer is C
Explanation
Rationale:
A. Don sterile gloves prior to the procedure: Clean gloves, not sterile gloves, are required for a capillary blood glucose test since it is a clean, not sterile, procedure. Sterile technique is unnecessary and not cost-effective for this type of routine testing.
B. Hold the finger in an upright position prior to the procedure: The finger should be held in a dependent (downward) position to promote blood flow to the puncture site. Holding it upright may reduce perfusion and make obtaining an adequate sample more difficult.
C. Use the lateral tip of the finger to obtain specimen: The lateral sides of the fingertip have fewer nerve endings than the center and are more vascular, making them ideal for obtaining an adequate blood sample with minimal discomfort to the client.
D. Discard the lancet in the trash container: Lancets are sharp instruments and must be discarded in an approved sharps container to prevent needle-stick injuries and ensure proper infection control. Disposing of them in regular trash poses a safety hazard.
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