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 "{\"xRanges\":[111.828125,122.828125],\"yRanges\":[106.5,117.5]}"
Explanation
A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.
B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.
C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.
Correct Answer is C
Explanation
A. "I have switched from tobacco cigarettes to electronic cigarettes.": Although electronic cigarettes may reduce exposure to certain harmful chemicals found in tobacco smoke, they still pose significant health risks. This change does not reflect truly limiting risky behavior but rather substituting one form of risk for another.
B. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me.": Exposure to toxic chemicals, even without immediate harm, still represents ongoing risk. A proactive approach would involve using protective equipment or seeking safer work conditions.
C. "Two of my grandparents had diabetes, so I try to eat a healthy diet.": Actively modifying diet in response to a family health history shows a positive, preventative approach and reflects conscious efforts to limit risk-taking behaviors and promote long-term health.
D. "My job and home life are both very stressful, but I haven't been able to do anything about that.": Chronic unmanaged stress is a health risk, and acknowledging stress without taking steps to manage it indicates that the client is not effectively limiting risk behaviors.
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