A nurse is caring for a client on a medical-surgical unit.
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. Click to highlight the findings below that the nurse should report to the provider.
Nurses Notes
Oxygen saturation 95%
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
Oxygen saturation 95%
The Correct Answer is ["A","B","C","D","E","F"]
The nurse should report the hoarseness of the client's voice, which could indicate recurrent laryngeal nerve damage, which is a risk associated with thyroid surgery. Tingling around the mouth may suggest hypocalcemia, a common complication after thyroidectomy due to accidental removal or damage to the parathyroid glands. The moderate serosanguinous drainage on the neck dressing could signify bleeding or infection, which requires immediate attention. The noted tremor in both hands and the increase in temperature could be signs of a thyroid storm, a rare but life-threatening condition.
Furthermore, the client's restlessness could be a response to discomfort or could indicate a more serious issue, such as an impending thyrotoxic crisis. Oxygen saturation at 95% is within normal limits postoperatively; however, it should be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Having a pacemaker is not a contraindication for kidney transplant unless there are significant underlying cardiac issues that would increase the risks associated with surgery.
B. Chronic alcohol abuse can lead to multiple organ damage and increased surgical risks, making it a contraindication for kidney transplant.
C. Being a breast cancer survivor is not a contraindication for kidney transplant unless there are active cancer or metastases that would affect surgical outcomes.
D. Age alone is not a contraindication for kidney transplant. The decision for transplant candidacy is based on overall health status and comorbidities rather than age alone.
Correct Answer is C
Explanation
A. Making a list of favorite beverages shows awareness but does not necessarily indicate an understanding of fluid restriction.
B. Putting beverages in large containers to deceive fluid intake is not a recommended or appropriate strategy for managing fluid restriction.
C. Not adding fluid-rich foods like ice cream to the total fluid intake demonstrates an understanding of fluid restriction and adherence to the prescribed limit.
D. Consuming most fluids during the evening is not an appropriate strategy for fluid restriction; fluid intake should be evenly distributed throughout the day.
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