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?

Client report of nausea

Serosanguineous drainage

Muscle twitching

Client report of incisional pain

Answer and Explanation

The Correct Answer is C

C. Muscle twitching post-thyroidectomy can indicate hypocalcemia, a common complication due to inadvertent damage or removal of the parathyroid glands during surgery. Hypocalcemia can lead to neuromuscular irritability, including muscle twitching, tingling, or tetany.

A Nausea is a common postoperative symptom and can be caused by anesthesia, pain medications, or changes in gastrointestinal function. While uncomfortable, nausea alone is typically not an urgent concern

B Serosanguineous drainage (thin, pink-tinged fluid) from the surgical incision is expected in the early postoperative period. It indicates normal wound healing and does not usually require urgent attention

D. Routine incisional pain does not typically require urgent reporting unless accompanied by other concerning symptoms.

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Correct Answer is D

Explanation

D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.

A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.

B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.

C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.

A. Arrythmia B. Laryngeal edema C. Hypertension D. Fever

Correct Answer is B

Explanation

B. Laryngeal edema, or swelling of the larynx (voice box), is a hallmark feature of severe anaphylaxis. It can lead to airway obstruction and respiratory distress, which are critical components of an anaphylactic reaction.

A Arrhythmias (abnormal heart rhythms) can occur as a result of various causes, including medications, but they are not specific to anaphylaxis. They may or may not be present during an anaphylactic reaction.

C. Hypertension (high blood pressure) is not a typical feature of anaphylaxis. Instead, hypotension (low blood pressure) is more commonly associated with anaphylactic shock, which is a severe form of anaphylaxis.

D. Fever is not typically associated with anaphylaxis. Anaphylactic reactions typically involve rapid onset of symptoms such as flushing, hives, swelling, respiratory distress, and potentially cardiovascular collapse, but not fever.

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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 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?

Correct Answer is D

Explanation

A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?

Correct Answer is B

Explanation

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