What is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post- thyroidectomy?
Anticipate and monitor for hypothermia.
Prepare to administer radioactive iodine treatments.
Resume antithyroid drug therapy.
Maintain a semi-Fowler position.
The Correct Answer is A
Choice A rationale
Anticipating and monitoring for hypothermia is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post-thyroidectomy. The thyroid gland plays a significant role in regulating the body’s metabolism, including temperature regulation. After a thyroidectomy, the body may struggle to regulate temperature, leading to hypothermia. The nurse should monitor the patient’s temperature regularly and provide warming measures as needed.
Choice B rationale
Preparing to administer radioactive iodine treatments is not the most crucial intervention at this time. Radioactive iodine is typically used as a treatment for hyperthyroidism or thyroid cancer, not as an immediate post-operative intervention.
Choice C rationale
Resuming antithyroid drug therapy is not the most crucial intervention at this time. Antithyroid drugs are used to treat hyperthyroidism, and their use would need to be evaluated based on the reason for the thyroidectomy and the patient’s post-operative thyroid hormone levels.
Choice D rationale
Maintaining a semi-Fowler position can be beneficial for comfort and respiratory function post-operatively, but it is not the most crucial intervention. The nurse should assist the patient to a comfortable position and encourage regular deep breathing and coughing exercises to prevent respiratory complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.
Correct Answer is C,A,B,D
Explanation
Step 1: Complete a focused assessment. The first step in managing a patient with abdominal pain and distention, vomiting, and constipation is to perform a focused assessment. This includes assessing the patient’s vital signs, pain level, abdominal distention, bowel sounds, and any other relevant physical findings.
Step 2: Elevate the head of the bed. Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited.
Step 3: Send the emesis sample to the lab. Analyzing the vomitus can provide important information about the possible causes of the patient’s symptoms. For example, the presence of blood could suggest a gastrointestinal bleed.
Step 4: Offer PRN pain medication. After the initial assessment and interventions, the nurse should address the patient’s comfort. Pain management is an important part of patient care, but in this scenario, it is not the highest priority.
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