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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
Administering IV fluids is a potential nursing intervention for several body systems. For example, the circulatory system may require IV fluids to maintain blood volume and pressure. The renal system may need IV fluids to ensure adequate urine output. The digestive system might need IV fluids to compensate for losses from vomiting or diarrhea.
Choice B rationale
Assessing a rash is a potential nursing intervention for the integumentary system. Rashes can be a sign of many different conditions, including allergic reactions, infections, autoimmune diseases, and more. By assessing the rash, the nurse can gather information to help determine its cause and appropriate treatment.
Choice C rationale
Administering an antihistamine is a potential nursing intervention for the immune system. Antihistamines are often used to treat allergic reactions, which involve the immune system.

They can also be used to treat symptoms of the common cold, which is caused by a viral infection.
Choice D rationale
Administering a steroid is a potential nursing intervention for several body systems. Steroids can be used to reduce inflammation, which can benefit the musculoskeletal, integumentary, respiratory, and other systems. They can also be used to treat certain endocrine disorders.

A. Ventilation B. Neurological status C. Exposure D. Current medications E. Allergies F. Circulation

Correct Answer is ["A","B","C","F"]

Explanation

The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.

Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.

Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).

Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.

Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.

Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.

Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.

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What is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post- thyroidectomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

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