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 B

Explanation

B. Respiratory infections can spread via droplets, necessitating airborne precautions and isolation in a private negative pressure room to prevent transmission to other clients and healthcare workers.

A A compound fracture involves an open wound where the bone has punctured the skin. While this client may require isolation precautions due to the open wound, the primary concern is not infectious in nature.

C. Aspiration pneumonia can be caused by inhalation of oral or gastric contents into the lungs, leading to infection. Therefore, such a client does not require isolation.

D Acute ketoacidosis in diabetes mellitus is a metabolic emergency but is not typically contagious or requiring isolation precautions for infection control.

A. Client reports tightness in chest that radiates to left arm B. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast C. Client is diaphoretic and short of breath D. Heart rate irregular and tachycardic E. I had scrambled eggs and bacon like I do every morning F. Lungs clear to auscultation in all lobes G. +1 pedal pulses H. Capillary refill less than 2 seconds

Correct Answer is ["A","B","C","D"]

Explanation

Client reports tightness in chest that radiates to left arm: Chest tightness that radiates to the left arm is a classic symptom of myocardial ischemia or infarction (heart attack). This symptom is concerning because it suggests potential heart muscle damage or decreased blood flow to the heart.

States pain as 7 on a scale of 0 to 10: The client rates their chest pain as 7 out of 10. This indicates significant discomfort and suggests that the chest tightness is causing substantial pain. Pain severity is an important indicator in assessing the severity of the cardiac event.

Started to feel nauseous after breakfast: Nausea can be a symptom associated with myocardial ischemia or infarction, particularly when it occurs after physical exertion or a meal. It can be caused by decreased blood flow to the gastrointestinal tract due to compromised cardiac function.

Client is diaphoretic and short of breath: Diaphoresis (excessive sweating) and shortness of breath are additional symptoms that commonly accompany acute myocardial infarction. Diaphoresis occurs due to sympathetic nervous system activation, while shortness of breath can result from decreased cardiac output or pulmonary congestion.

Heart rate irregular and tachycardic: An irregular and tachycardic (rapid) heart rate is abnormal and suggests cardiac dysrhythmia, which can occur in response to myocardial ischemia or infarction. It reflects the heart's attempt to compensate for reduced oxygen delivery to the body.

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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 charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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