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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:
Determining the client's understanding of the procedure is important as it ensures informed consent and can help alleviate anxiety. However, while this is a necessary part of preoperative care, it may not be the immediate priority¹.

Choice B reason:
Establishing the need for psychological support is a valuable aspect of holistic care. It addresses the client's emotional well-being and can improve overall satisfaction with the surgical experience. Nonetheless, it is not the primary focus of the preoperative assessment².

Choice C reason:
Identifying possible surgical risks is the priority in a preoperative assessment. This includes evaluating the client's medical history, current health status, and any factors that could increase the risk of complications during or after surgery. A thorough risk assessment is crucial for planning safe surgical care and for making decisions about proceeding with the surgery¹³.

Choice D reason:
Recognizing resources needed postoperatively is part of discharge planning and is essential for ensuring continuity of care. While it is an important consideration, it is not the immediate priority during the preoperative assessment².

A. Ecchymosis of the surrounding skin B. Acute pain C. Bounding distal pulse D. Increasing edema

Correct Answer is D

Explanation

Choice A reason:
Ecchymosis, or bruising, of the surrounding skin is a common finding associated with fractures due to the trauma to blood vessels in the area. While it can indicate bleeding or injury, ecchymosis itself does not specifically indicate impaired venous return.

Choice B reason:
Acute pain is a typical symptom following a fracture and results from the injury to the bone and surrounding tissues. Pain is an expected finding and does not directly suggest an issue with venous return.

Choice C reason:
A bounding distal pulse may actually suggest increased arterial flow or could be a sign of other conditions such as high blood pressure or fever. It does not indicate impaired venous return, which is typically characterized by a lack of pulse or a very weak pulse.

Choice D reason:
Increasing edema, or swelling, in the affected arm is a sign of impaired venous return. When veins are unable to effectively return blood to the heart, fluid can accumulate in the tissues, leading to edema. In the context of a fracture, this could be due to compression or damage to the veins, which can impede blood flow and result in swelling.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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