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 A
Explanation
Choice A reason:
Nausea and vomiting are common symptoms of peritonitis, which can occur in clients receiving peritoneal dialysis. These symptoms result from the irritation and inflammation of the peritoneum, the membrane lining the abdominal cavity.
Choice B reason:
Hyperactive bowel sounds are not typically associated with peritonitis. In fact, bowel sounds may be diminished or absent due to the inflammatory process and potential ileus associated with peritonitis.
Choice C reason:
Bradycardia, or a slower than normal heart rate, is not a common manifestation of peritonitis. Peritonitis can cause tachycardia, an increased heart rate, as the body responds to inflammation and infection.
Choice D reason:
Increased urinary output is not a manifestation of peritonitis. Peritoneal dialysis involves the peritoneal cavity and not the urinary system directly. Peritonitis may actually lead to decreased urine output if the infection causes systemic effects.
Correct Answer is B
Explanation
Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.
Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.
Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.
Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.
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