The nurse has reviewed the Vital Signs at 1000.
For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.
Administer aspirin for fever
Apply cooling blanket
Monitor vital signs every 4 hours
Place client on telemetry
Palpate thyroid area to assess for hematoma
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.
• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.
• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.
• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.
• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pain relieved by the prone position: Pain from acute pancreatitis is typically not relieved by lying prone. Clients often find some relief by sitting up, leaning forward, or assuming a fetal position, as these positions reduce pressure on the inflamed pancreas.
B. Decreased WBC count: Acute pancreatitis usually triggers an inflammatory response, leading to an elevated white blood cell (WBC) count, not a decreased one. Leukocytosis is a common laboratory finding associated with the body's reaction to inflammation and possible infection.
C. Hyperactive bowel sounds: In acute pancreatitis, bowel sounds are often decreased or absent due to paralytic ileus. Hyperactive bowel sounds would be more suggestive of other gastrointestinal disturbances such as diarrhea or early intestinal obstruction.
D. Epigastric pain: Severe, persistent epigastric pain that may radiate to the back is the hallmark symptom of acute pancreatitis. This pain is typically sudden in onset and worsens after eating or drinking, especially fatty foods.
Correct Answer is D
Explanation
A. Provide the client with low-calorie formula: The calorie content of the formula is not typically responsible for diarrhea. Diarrhea is more often related to formula intolerance, contamination, or rapid feeding rates rather than calorie density.
B. Increase the rate of the client's feeding: Increasing the rate can worsen diarrhea by overwhelming the gastrointestinal system, leading to poor absorption and increased fluid loss. Slower rates are often needed if diarrhea occurs.
C. Switch the client to a formula containing less protein: Protein content is usually not the cause of diarrhea. Specialized formulas may be needed for certain conditions, but protein itself is not typically a trigger for diarrhea.
D. Administer the client's formula at room temperature: Cold formula can cause gastric cramping and diarrhea. Administering the formula at room temperature helps reduce gastrointestinal irritation and promotes better tolerance of the feeding.
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