The nurse is caring for a client after a total thyroidectomy. The nurse's priority should be to:
Encourage the client to cough and deep breathe every two hours, with her neck in a flexed position.
Maintain the client in a Fowler's position, with head neutral supported by pillows.
Maintain the client in a supine position, with sandbags placed on either side of her head and neck.
Encourage the client to turn head side to side, to promote drainage of oral secretions.
The Correct Answer is B
Choice A Reason: Encouraging the client to cough and deep breathe every two hours, with her neck in a flexed position, is not a priority for a client after a total thyroidectomy, as it may increase the risk of bleeding or damage to the surgical site.
Choice B Reason: Maintaining the client in a Fowler's position, with head neutral supported by pillows, is a priority for a client after a total thyroidectomy, as it helps to reduce swelling and edema, prevent airway obstruction, and promote venous drainage.
Choice C Reason: Maintaining the client in a supine position, with sandbags placed on either side of her head and neck, is not a priority for a client after a total thyroidectomy, as it may impair breathing and circulation, increase pressure on the surgical site, and cause neck stiffness.
Choice D Reason: Encouraging the client to turn head side to side, to promote drainage of oral secretions, is not a priority for a client after a total thyroidectomy, as it may cause pain and discomfort, disrupt the sutures or drains, and increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: N0 does not indicate presence of regional lymph node involvement, but absence of it. N1 to N3 indicate increasing degrees of regional lymph node involvement.
Choice B Reason: TIS does not indicate that a tumor has been resolved, but that it is in situ, meaning that it is confined to the original site and has not invaded deeper tissues.
Choice C Reason: T4 does not indicate a tumor at its smallest size, but at its largest size. T1 to T4 indicate increasing sizes or extents of the primary tumor.
Choice D Reason: M1 indicates tumor metastasis to a single site, meaning that the cancer has spread to another organ or distant lymph node. M0 indicates no distant metastasis.
Correct Answer is D
Explanation
Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
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