A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Place the head of the client's bed in the flat position.

Instruct the client to deep breathe every 4 hr.

Hyperextend the client's neck.

Check the client's voice every 2 hr.

Answer and Explanation

The Correct Answer is D

- Choice A Rationale: Placing the head of the bed in the flat position is not recommended as it can increase the risk of airway obstruction and reduce venous drainage from the head, which is especially critical after thyroid surgery.
- Choice B Rationale: While deep breathing is important postoperatively, it is not specific to thyroidectomy care and should be done more frequently than every 4 hours to ensure adequate ventilation and prevent atelectasis.
- Choice C Rationale: Hyperextending the client's neck can be harmful post-thyroidectomy as it may put stress on the surgical site, potentially leading to dehiscence or damage to the area.
- Choice D Rationale: Checking the client's voice every 2 hours is essential after a thyroidectomy because vocal cord paralysis can be an indicator of recurrent laryngeal nerve damage, which is a potential complication of the surgery. Monitoring the voice allows for early detection and intervention.

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Correct Answer is C

Explanation

A. Checking the pedal pulses is important for assessing circulation, but it may not directly address the cause of the muscle spasms. In this case, addressing the electrolyte imbalance is a higher priority.

B. Requesting a relaxant might provide temporary relief for muscle spasms, but it does not address the potential underlying cause. It's important to identify and treat the root issue.

C. Correct. Severe muscle spasms in a client post-thyroidectomy could indicate hypocalcemia, as the parathyroid glands, which regulate calcium levels, can be affected during the surgery. Verifying the most recent calcium level will help determine if this is the cause.

D. Administering an oral potassium supplement addresses a different electrolyte imbalance (hypokalemia), which is not typically associated with muscle spasms following a thyroidectomy. Calcium levels are more relevant in this context.

A. Provide 2 units insulin aspart 50 B. Provide 6 units insulin aspart 50 C. Provide 10 units insin apart SQ D. Provide 4 units insulin aspart 50

Correct Answer is B

Explanation

A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.

B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.

C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.

D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.

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A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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