While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

The patient’s voice is weak and hoarse sounding.

The patient is complaining of a 7/10 incisional pain.

The patient’s cardiac monitor shows a heart rate of 112.

The patient is increasingly swelling at the neck.

Answer and Explanation

The Correct Answer is D

This is a critical finding that could indicate bleeding or compromised airway, both of which are potentially life-threatening complications following a thyroidectomy. Immediate intervention may be necessary to prevent further harm to the patient. The other options are important to note and should be addressed, but they do not require immediate intervention as the swelling in the neck does.

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Correct Answer is C

Explanation

Before administering any medication, the nurse should confirm the potassium level to ensure that it is still elevated and needs to be treated. Potassium levels can ﬂuctuate, so repeating the test will ensure that the client receives the appropriate treatment.

Options (a) Withhold the medication and (b) Administering a hypertonic solution may be appropriate interventions depending on the client's condition, but confirming the potassium level is the first step.

Option (d) Monitoring for paresthesia is important but not the first action that the nurse should take.

A. You really should not worry about how you look in the hospital, we see many worse things. B. Most of the physical and mental changes caused by the disease will gradually improve after surgery. C. "Let me show you how to dress so that the changes are not so noticeable." D. "I do not think you look bad; your appearance is just altered by your disease.

Correct Answer is B

Explanation

This response acknowledges the patient's concerns and provides reassurance that the changes are temporary and will improve after surgery. Response is dismissive of the patient's concerns and may make the patient feel unheard. Response c may be helpful, but it does not address the patient's emotional concerns. Response d is not accurate because the patient has expressed feeling awful about their appearance.

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While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A patient with crushing syndrome is admited to the hospital to have laparoscopic adrenalectomy. During the admission assessment, the patient tells the nurse "The worst thing about this disease is how terrible I look; I feel awful about it.' The best response by the nurse is:

Correct Answer is B

Explanation

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