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 B
Explanation
Choice A Reason: The presence of edema in the external auditory canal is not a sign of cerumen impaction, but it may indicate other conditions such as otitis externa or allergic reaction.
Choice B Reason: A yellowish or brownish waxy material in the external auditory canal is a sign of cerumen impaction, as it shows that there is excess or hardened earwax that blocks the ear canal.
Choice C Reason: Redness and swelling of the tympanic membrane are not signs of cerumen impaction, but they may indicate other conditions such as otitis media or trauma.
Choice D Reason: An external auditory canal that is longer than normal is not a sign of cerumen impaction, but it may be a normal variation or a result of aging.
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason: Cloudy urine is a finding that indicates a urinary tract infection, as it shows that there are bacteria, pus, or blood in the urine.
Choice B Reason: Muscle tetany is not a finding that indicates a urinary tract infection, but it may indicate other conditions such as hypocalcemia or alkalosis.
Choice C Reason: Presence of calculi is not a finding that indicates a urinary tract infection, but it may cause or complicate a urinary tract infection by obstructing the urine flow and creating a nidus for bacterial growth.
Choice D Reason: Urinary frequency is a finding that indicates a urinary tract infection, as it shows that there is irritation and inflammation of the bladder and urethra.
Choice E Reason: Dysuria is a finding that indicates a urinary tract infection, as it shows that there is pain or burning sensation during urination.
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