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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling.
Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets.
B. Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during
suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.
C. Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.
D. Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning
procedure.

A. Assist the client with clarifying values about end-of-life care options. B. Ask the client how often episodes of sundowning are experienced. C. Request to have the client lie as still as possible for the assessment. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

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Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post-thyroidectomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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