A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Neck stiffness

Hoarseness

Moderate serosanguineous drainage

Muscle twitching

Answer and Explanation

The Correct Answer is D

Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A.   Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B.   Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C.   Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D.   Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.

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Correct Answer is B

Explanation

B. Ondansetron is a commonly used medication for preventing nausea and vomiting induced by chemotherapy. It belongs to a class of drugs called serotonin receptor antagonists, which work by blocking serotonin receptors in the brain and gastrointestinal tract, thereby reducing the sensation of nausea and the urge to vomit. Ondansetron is often administered prior to chemotherapy to help prevent these side effects.
A. Diphenhydramine works by blocking histamine receptors in the brain that trigger nausea and vomiting. However, it is not commonly used as a first-line antiemetic for chemotherapy-induced nausea and vomiting.
C. Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant and is not used specifically for preventing chemotherapy-induced nausea and vomiting.
D. Methylprednisolone is a corticosteroid medication that has anti-inflammatory and immunosuppressant effects.

A. Move the client up and down in bed by holding onto the halo traction device. B. Ensure that there is space for one finger to fit between the vest and the client's skin. C. Apply medicated powder under the vest to reduce itching. D. Loosen or tighten the screws on the device as needed for the client's comfort.

Correct Answer is B

Explanation

B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.

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A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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