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
Client report of incisional pain
Serosanguineous drainage
Muscle twitching
The Correct Answer is D
A. Client report of nausea:
Nausea is a common postoperative symptom that can occur due to anesthesia, pain medications, or other factors. While it is important to manage nausea to ensure the client's comfort and prevent complications like aspiration, it is not as urgent as other potential postoperative complications following a thyroidectomy.
B. Client report of incisional pain:
Incisional pain is expected after surgery and can typically be managed with pain medications. Although it is important to ensure that the client’s pain is adequately controlled, it is not usually indicative of a life-threatening complication and is a normal part of the postoperative healing process.
C. Serosanguineous drainage:
Serosanguineous drainage, a mix of blood and serum, is a typical finding in the early postoperative period and usually indicates normal wound healing. While excessive or unusual drainage should be monitored, small amounts are generally not a cause for immediate concern unless accompanied by signs of infection or other complications.
D. Muscle twitching:
Muscle twitching can indicate hypocalcemia, a potential complication following thyroidectomy due to accidental removal or damage to the parathyroid glands. Hypocalcemia can lead to serious conditions such as tetany or cardiac dysrhythmias. Therefore, muscle twitching is a priority finding that needs immediate reporting and intervention to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Leukocytosis:
Lisinopril, an ACE inhibitor, is not commonly associated with leukocytosis (an increase in white blood cells). This finding is more typical of infections or inflammatory conditions rather than a side effect of lisinopril.
B) Cough:
A persistent dry cough is a well-known adverse effect of lisinopril and other ACE inhibitors. This occurs due to the accumulation of bradykinin and substance P in the respiratory tract. Patients often report this side effect, and it may require switching to a different class of antihypertensive medication.
C) Hypokalemia:
Lisinopril usually does not cause hypokalemia (low potassium levels). In fact, ACE inhibitors can lead to hyperkalemia (high potassium levels) due to reduced aldosterone production, which normally promotes potassium excretion.
D) Bradycardia:
Bradycardia (slow heart rate) is not a typical adverse effect of lisinopril. This medication primarily affects blood pressure through vasodilation and reduction of fluid volume rather than directly influencing heart rate.
Correct Answer is A
Explanation
A) The client advances the weaker leg forward to the cane:
Advancing the weaker leg forward to the cane demonstrates the correct use of the quad cane. This technique helps to provide support and stability, allowing the client to maintain balance while transferring weight onto the cane and weaker leg.
B) The client holds the cane with their left hand:
Holding the cane with the left hand is incorrect for a client with left-sided weakness. The cane should be held in the hand opposite the weaker side, which would be the right hand in this case, to ensure optimal balance and support.
C) The client takes a step with their right foot first:
Taking a step with the right foot first does not indicate proper use of the cane. The correct sequence involves moving the cane and the weaker leg forward together, followed by the stronger leg to maintain stability and support.
D) The client moves the cane 2 feet ahead:
Moving the cane 2 feet ahead is too far and can compromise the client’s balance. The cane should be moved a short distance, typically about 6 to 12 inches, to provide steady support and prevent falls.
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