Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?
Resume antithyroid drug therapy.
Anticipate and monitor for hypothermia.
Prepare to administer radioactive iodine treatments.
Maintain a semi-Fowler position.
The Correct Answer is D
A. Resume antithyroid drug therapy.
Antithyroid medications are typically not resumed immediately post-thyroidectomy unless specifically directed by the healthcare provider. The focus post-surgery is often on managing potential complications and ensuring proper healing.
B. Anticipate and monitor for hypothermia.
Hypothermia is not a common concern following thyroidectomy. The nurse should monitor for other more relevant complications such as bleeding, airway obstruction, and hypocalcemia.
C. Prepare to administer radioactive iodine treatments.
Radioactive iodine treatment is usually not administered immediately post-thyroidectomy. It may be considered later, depending on the reason for the thyroidectomy and the individual treatment plan.
D. Maintain a semi-Fowler position.
This is the correct intervention. Maintaining the client in a semi-Fowler position helps reduce strain on the surgical site, facilitates breathing, and minimizes the risk of complications such as bleeding and edema in the neck area. It is an essential part of postoperative care for
thyroidectomy patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer aspirin to prevent further clot formation and platelet clumping. While aspirin may be indicated in the treatment of ischemic stroke, it is not the immediate priority. The client requires further assessment and diagnostic evaluation before initiating specific treatments.
B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence.
C. Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis and
determine eligibility for thrombolytic therapy.
D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets the
criteria for this time-sensitive intervention.
Correct Answer is C
Explanation
A. 2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B. Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.
C. Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D. Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as
immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.
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