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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Generalized urticaria, or hives, is not a common side effect of radiation therapy for lung cancer. While skin reactions can occur, they are usually localized to the area being treated. Urticaria might be a sign of an allergic reaction, which would require immediate attention, but it is not typically associated with radiation therapy¹.
Choice B reason:
Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the radiation field includes salivary glands. For lung cancer patients, if the radiation field is near the neck or upper chest, it could potentially affect salivary gland function. Monitoring for xerostomia is important because it can lead to difficulties in speaking, eating, and swallowing, and it increases the risk for dental problems².
Choice C reason:
While reviewing laboratory test results for low hemoglobin is an important part of nursing care, it is not specific to radiation therapy for lung cancer. Low hemoglobin could be related to the cancer itself or a side effect of other treatments like chemotherapy. It is important to monitor, but not the primary action related to radiation therapy³.
Choice D reason:
Observing for signs of infection is a general nursing responsibility for all patients, not specific to those receiving radiation therapy for lung cancer. However, if the patient's immune system is compromised due to the cancer or other treatments, vigilance for infection is heightened.
Correct Answer is A
Explanation
Choice A reason: An elevated oral temperature of 38.2°C (100.76°F) postoperatively can indicate an infection, which is a common complication after surgical procedures. In the context of TURP, a fever could suggest a urinary tract infection or sepsis, especially if accompanied by other symptoms such as chills or an elevated white blood cell count.
Choice B reason: The output of burgundy-colored urine can be expected in the immediate postoperative period following a TURP due to bleeding. However, it should gradually lighten in color. Persistent or worsening hematuria could indicate a complication, but it is not uncommon to see some blood in the urine shortly after the procedure
Choice C reason: A pulse rate of 88/min is within the normal range (60-100 beats per minute) and is not typically indicative of a postoperative complication. It is important to consider the patient's baseline heart rate and any other symptoms they may be experiencing.
Choice D reason: Feeling an urge to void despite having an indwelling urinary catheter can occur due to bladder spasms or irritation from the catheter itself. While uncomfortable, this sensation is not uncommon after TURP and does not necessarily indicate a complication.
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