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The nurse has reviewed the Nurses' Notes and Vital Signs at 1200.

Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?

Hoarseness

Drainage

Sensation

Vital signs

Pain assessment

Answer and Explanation

Correct Answer : C,D

Hoarseness: Mild hoarseness is a common temporary effect after thyroid surgery due to irritation or swelling near the recurrent laryngeal nerve. While it needs monitoring, slight hoarseness alone is not necessarily a sign of a serious complication if it is not worsening or associated with airway compromise.
Drainage: A moderate amount of serosanguineous drainage from the incision site is expected after surgery. Although the drainage should continue to be monitored for increase or color change, the amount described here is not immediately concerning for a postoperative complication.
Sensation: The client reports tingling in the fingers, which suggests hypocalcemia due to accidental removal or damage to the parathyroid glands during surgery. Hypocalcemia is a serious complication of thyroidectomy that can progress to muscle cramps, tetany, and seizures if untreated.
Vital signs: The client’s rising temperature, tachycardia, hypertension, and increased respiratory rate are concerning for a developing thyroid storm, a rare but life-threatening complication after thyroid surgery. These vital signs warrant immediate intervention to prevent rapid deterioration.
Pain assessment: A pain score of 3 out of 10 is mild and expected following surgery. This level of discomfort is manageable and not indicative of a major complication, provided it does not rapidly escalate or localize severely around the surgical site.

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Correct Answer is B

Explanation

A. Ringing in the ears: Ringing in the ears (tinnitus) is not a common adverse effect of enoxaparin. It is typically associated with medications like aspirin or other salicylates, not low-molecular-weight heparins like enoxaparin.

B. Black, tarry stools: Black, tarry stools are a sign of gastrointestinal bleeding, which is a serious potential adverse effect of anticoagulant medications like enoxaparin. Clients taking enoxaparin should be instructed to report this symptom immediately, as it could indicate internal bleeding.

C. Fine hand tremors: Fine hand tremors are not a known adverse effect of enoxaparin. They are more commonly associated with other medications, such as certain psychiatric drugs or neurologic conditions.

D. Diarrhea: Diarrhea is not a common adverse effect of enoxaparin. While gastrointestinal symptoms can occur with many medications, it is not a primary concern or indication for discontinuing enoxaparin.

A. WBC count 12,000/mm3 (5,000 to 10,000/mm3) B. Temperature 37.8° C (100° F) C. Respiratory rate 16/min D. Hgb 8 g/dL (less than 11 g/dL)

Correct Answer is D

Explanation

A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.

B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.

C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.

D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.

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The nurse has reviewed the Nurses' Notes and Vital Signs at 1200. Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?

Nursing Test Bank

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Correct Answer is D

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The nurse has reviewed the Nurses' Notes and Vital Signs at 1200.

Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?