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 A

Explanation

Choice A reason:
It is essential to dry the prosthesis socket completely before applying it to the limb to prevent any moisture-related issues, such as skin irritation or infection. Moisture can create an environment conducive to bacterial growth and can also cause the prosthesis to slip or not fit properly.

Choice B reason:
While it is important to keep the skin of the stump moisturized, applying lotion or oil immediately before putting on the prosthesis is not advised. Lotions and oils can make the skin slippery, leading to a poor fit of the prosthesis or even causing the prosthesis to slip off. It is better to apply moisturizer at a time when the prosthesis will not be worn for a while, allowing the skin to absorb the lotion fully.

Choice C reason:
The prosthesis should not be in direct contact with the residual limb without proper padding or a liner. Direct contact can lead to pressure sores, skin irritation, and discomfort. Properly fitted socks or liners should be used to cushion the limb and ensure a comfortable, secure fit.

Choice D reason:
While some skin irritation may be expected when first using a prosthesis, persistent irritation is not normal and should be addressed by a healthcare provider. The prosthesis may need to be adjusted, or there may be an issue with the fit or the materials used. Skin irritation should not be accepted as a standard part of using a prosthesis.

A. The lesions are contagious to others only if they are draining. B. Vesicles will appear followed by pain and/or itching. C. Many clients experience pain in the affected area for weeks after the lesions have resolved. D. Herpes zoster is easily spread to family and friends who have had chickenpox in the past.

Correct Answer is ["A","B","C"]

Explanation

Choice A reason:
Herpes zoster lesions are indeed contagious if they are draining. The virus can spread through direct contact with the fluid from the blisters. It is crucial to cover the lesions to prevent spreading the virus to others, especially to those who have never had chickenpox or the vaccine.

Choice B reason:
The development of vesicles, which are small fluid-filled blisters, is a hallmark of herpes zoster. These vesicles typically appear in a band-like pattern on one side of the body and are often accompanied by pain, itching, or tingling before they are visible.

Choice C reason:
Postherpetic neuralgia is a condition where the pain persists in the area of the herpes zoster rash even after the lesions have healed. This can last for weeks, months, or even years and is more common in older adults.

Choice D reason:
Herpes zoster itself is not spread like chickenpox. It occurs when the varicella-zoster virus, which has been lying dormant in the nerve cells, reactivates. While it is possible for someone who has never had chickenpox to develop chickenpox after direct contact with a shingles rash, herpes zoster is not "easily spread" to others in the same way that chickenpox is.

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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?

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