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 C
Explanation
Choice A reason:
Hypertension is not typically an early manifestation of fat embolism syndrome (FES). FES is more commonly associated with hypoxemia, which can lead to hypotension rather than hypertension².
Choice B reason:
While a swollen calf may indicate deep vein thrombosis, it is not an early sign of FES. FES primarily affects the lungs and neurological systems early on, rather than causing localized swelling such as in a calf².
Choice C reason:
Tachypnea, or rapid breathing, is indeed an early sign of FES. This symptom usually develops before others and is due to the fat globules causing respiratory distress by blocking the pulmonary microcirculation²³⁴.
Choice D reason:
Bradycardia, or a slower than normal heart rate, is not an early sign of FES. Instead, patients may experience tachycardia as a response to hypoxemia and respiratory distress².
Correct Answer is D
Explanation
Choice A reason:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.
Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.
Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.
Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.
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