A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Serosanguineous drainage

Client report of incisional pain

Client report of nausea

Muscle twitching

Answer and Explanation

The Correct Answer is D

A) Serosanguineous drainage: While serosanguineous drainage can be expected after surgery, it is typically not alarming unless it significantly increases or changes in character. This finding alone does not indicate an immediate complication that requires urgent attention, making it a lower priority to report compared to other findings.

B) Client report of incisional pain: Postoperative pain is common and expected after a complete thyroidectomy. While the nurse should assess and manage the pain appropriately, this symptom is not unusual and does not signal a critical issue that would necessitate immediate reporting to the healthcare provider.

C) Client report of nausea: Nausea can occur after surgery due to anesthesia or medications. Although it should be addressed and managed, it is not a life-threatening complication. Therefore, this finding does not take priority over other more concerning symptoms.

D) Muscle twitching: Muscle twitching in a postoperative thyroidectomy patient may indicate hypocalcemia, a possible complication due to potential damage to the parathyroid glands during surgery. This condition can lead to severe complications if not addressed promptly, including tetany or seizures. Given the potential seriousness of this finding, it is critical for the nurse to report it to the healthcare provider immediately to ensure appropriate evaluation and intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Place the client's bed at the lowest height: This intervention is essential for safety. Lowering the bed height minimizes the risk of injury from falls, which is particularly important for clients with dementia who may experience disorientation or difficulty with mobility.

B) Request a prescription for a nightly sedative: While managing anxiety and agitation can be important, using sedatives in clients with dementia can lead to increased confusion, falls, and other complications. Non-pharmacological interventions are usually preferred.

C) Assist the client with toileting at least once every 4 hr: While promoting regular toileting is important, the frequency should be tailored to the individual's needs. Clients with dementia may require more frequent assistance based on their understanding and ability to communicate their needs.
D) Turn off all lights in the client's room at night: This could lead to disorientation and fear in clients with dementia. It's usually more beneficial to provide soft lighting to create a calming environment and reduce the risk of falls.

A. Avoid administering IV pain medication. B. Determine the client's blood type. C. Implement airborne precautions. D. Institute bleeding precautions

Correct Answer is D

Explanation

A) Avoid administering IV pain medication: While caution is warranted when administering IV medications to a client with petechiae, particularly if thrombocytopenia is suspected, avoiding pain management is not the appropriate action. Pain relief is crucial for the client’s comfort, and IV medications can be safely administered with proper precautions.

B) Determine the client's blood type: Knowing the client's blood type is important for transfusion purposes, especially if there is significant bleeding. However, this action is not the immediate priority in response to the observation of petechiae. The presence of petechiae is more directly related to bleeding risk rather than blood type.

C) Implement airborne precautions: Airborne precautions are necessary for certain infections (e.g., tuberculosis), but they are not indicated for the management of petechiae related to chronic lymphocytic leukemia. The presence of petechiae does not suggest an airborne infection; thus, this action does not address the immediate concern.

D) Institute bleeding precautions: Petechiae indicate a potential for bleeding due to thrombocytopenia, which is common in clients with chronic lymphocytic leukemia. Instituting bleeding precautions, such as using a soft toothbrush, avoiding invasive procedures, and monitoring for additional signs of bleeding, is crucial to prevent serious complications. Therefore, this action is the most appropriate and immediate response.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Correct Answer is A

Explanation

A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching?

A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication?

A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?

A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?