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: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason: History of alcohol abuse is an additional information that the nurse should obtain from this client, as it may indicate liver damage or cirrhosis, which can cause clay-colored stool due to reduced bile production or flow.
Choice B Reason: Intolerance to fatty foods is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate gallbladder disease or malabsorption.
Choice C Reason: Pain in the RUQ radiating to the shoulder is an additional information that the nurse should obtain from this client, as it may indicate gallstone obstruction or inflammation, which can cause clay-colored stool due to blocked bile ducts.
Choice D Reason: Pain in the McBurney's point is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate appendicitis or diverticulitis.
Choice E Reason: Bleeding ulcer is an additional information that the nurse should obtain from this client, as it may indicate upper gastrointestinal bleeding, which can cause clay-colored stool due to digested blood.
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