What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

"This IV infusion makes me urinate more often than usual."

"I'm most comfortable when the head of the bed is raised."

"The dressing over my incision feels like it is too tight."

"When I get out of bed quickly, I feel a little dizzy."

Answer and Explanation

The Correct Answer is C

A. Increased urination due to IV fluids is common and not immediately concerning.

B. Comfort with an elevated head of bed is typical postoperatively.

C. A tight dressing could indicate swelling or a potential complication such as hematoma, which can compromise the airway and requires immediate assessment.

D. Dizziness upon standing is common and not as urgent as potential airway compromise.

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Correct Answer is A

Explanation

A. Maintaining strict intake and output is crucial in managing septic shock as it helps to monitor fluid balance, which is essential for managing hypovolemia and ensuring adequate perfusion.

B. While assessing warmth of extremities is important, it is not as directly related to the immediate management of septic shock as monitoring intake and output.

C. Monitoring blood glucose levels is important, especially in septic patients, but it is not the primary focus in the initial management of septic shock.

D. Keeping the head of the bed raised 45 degrees can help with breathing but is not the most critical intervention in the immediate management of septic shock.

A. A resting respiratory rate of 35 breaths/minute. B. Flaring of the nares. C. Diaphragmatic respirations. D. Bilateral bronchial breath sounds.

Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

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What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Correct Answer is B

Explanation

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