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 D
Explanation
Rationale:
A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.
B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.
C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.
D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.
Correct Answer is C
Explanation
Rationale:
A. Veracity: Veracity refers to the obligation to tell the truth and provide accurate information. While withholding information could also violate this principle, the core issue in this scenario centers more on the client's right to make informed decisions rather than truth-telling alone.
B. Fidelity: Fidelity involves keeping promises and maintaining trust in the nurse-client relationship. While failing to inform the client may strain trust, the request from the parent specifically violates the client's right to participate in decisions about their care.
C. Autonomy: Autonomy is the right of individuals to make informed decisions about their own healthcare. Withholding information about medication side effects directly interferes with the client’s ability to provide informed consent, violating this fundamental ethical principle.
D. Justice: Justice involves fairness and equality in the distribution of care and resources. This principle is not directly implicated in the scenario, as the issue is not about fairness but about the individual’s right to know and decide.
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