A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Temperature
Urination
Pain control
Airway patency
The Correct Answer is D
Choice A reason:
Monitoring temperature is important postoperatively as it can indicate infection or inflammation. However, it is not the immediate priority following a thyroidectomy. The primary concern post-thyroidectomy is ensuring the airway is not compromised due to swelling or bleeding.
Choice B reason:
Monitoring urination is part of postoperative care to ensure kidney function and that the body is adequately eliminating fluids. While important, it is not the priority in the immediate postoperative period following a thyroidectomy.
Choice C reason:
Pain control is essential for patient comfort and recovery. However, while managing pain is a significant aspect of postoperative care, it is not the most critical priority following a thyroidectomy. The nurse must first ensure that the airway is clear.
Choice D reason:
Airway patency is the priority for monitoring a client post-thyroidectomy. Due to the proximity of the surgery to the trachea, there is a risk of swelling, hematoma, or other complications that could lead to airway obstruction. Ensuring the client has a patent airway is crucial to prevent respiratory distress or compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.
Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.
Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.
Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.
Correct Answer is C
Explanation
Choice A reason:
Lightheadedness is generally not an indication of effective treatment for dehydration. It is often a symptom of dehydration itself, as it can result from decreased blood volume and reduced blood flow to the brain. Effective rehydration should alleviate symptoms like lightheadedness, not present as an indication of it.
Choice B reason:
Decreased pulse pressure may indicate a drop in the volume of blood circulating through the body, which is not a sign of effective rehydration. Pulse pressure is the difference between systolic and diastolic blood pressure readings, and a narrow pulse pressure can be a sign of hypovolemia, or low blood volume, often due to dehydration.
Choice C reason:
Urine output of 75 mL in 1 hr can be considered within the normal range of urine output for an adult, which is typically about 0.5 to 1 mL/kg/hr⁵. This indicates that the kidneys are functioning and the body is excreting waste, suggesting effective rehydration.
Choice D reason:
A urine specific gravity of 1.038 is higher than the normal range of 1.005 to 1.030[^10^]. This indicates concentrated urine, which is commonly seen in dehydration as the body attempts to conserve water. Therefore, this is not an indication of effective treatment for dehydration.
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