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 B

Explanation

A. While reassuring the client about visiting arrangements is supportive, it is not as critical for ensuring continuity of care.

B. Obtaining a detailed report from the transferring nurse is crucial to ensure all relevant information and the client’s wishes are communicated effectively.

C. Providing written information about end-of-life care is helpful but secondary to ensuring accurate communication of the client’s care preferences.

D. Marking the chart is important, but the immediate priority is ensuring the complete and accurate transfer of care information.

A. Insert a urinary catheter for an uncomplicated client. B. Titrate oxygen to the prescribed parameters. C. Procure platelet products from the blood bank. D. Monitor an IV infusion rate on an established schedule.

Correct Answer is C

Explanation

A. Inserting a urinary catheter is a skill that typically requires a licensed nurse's expertise.

B. Titrating oxygen requires assessment and adjustment based on clinical findings, which is outside the UAP’s scope of practice.

C. Procuring platelet products from the blood bank is a non-clinical task that can be safely assigned to a UAP.

D. Monitoring an IV infusion rate involves clinical judgment and is typically performed by a licensed nurse.

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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

Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

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