A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?

Temperature

Urination

Pain control

Airway patency

Answer and Explanation

The Correct Answer is D

Choice A reason:
Monitoring temperature is important postoperatively as it can indicate infection or inflammation. However, it is not the immediate priority following a thyroidectomy. The primary concern post-thyroidectomy is ensuring the airway is not compromised due to swelling or bleeding.

Choice B reason:
Monitoring urination is part of postoperative care to ensure kidney function and that the body is adequately eliminating fluids. While important, it is not the priority in the immediate postoperative period following a thyroidectomy.

Choice C reason:
Pain control is essential for patient comfort and recovery. However, while managing pain is a significant aspect of postoperative care, it is not the most critical priority following a thyroidectomy. The nurse must first ensure that the airway is clear.

Choice D reason:
Airway patency is the priority for monitoring a client post-thyroidectomy. Due to the proximity of the surgery to the trachea, there is a risk of swelling, hematoma, or other complications that could lead to airway obstruction. Ensuring the client has a patent airway is crucial to prevent respiratory distress or compromise.

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Correct Answer is C

Explanation

Choice A reason:
Using chemotherapy instead of radiation may not be a viable option as the treatment plan is based on the type and stage of cancer. Chemotherapy can also affect fertility, so it is not a direct solution to the concern of infertility.

Choice B reason:
Fertility medications during treatment might help preserve fertility, but they do not address the direct impact of radiation on reproductive organs. Additionally, the use of such medications should be discussed with an oncologist and a fertility specialist.

Choice C reason:
Radiation shielding techniques involve using protective shields to limit radiation exposure to the reproductive organs. This can help reduce the risk of infertility caused by radiation, especially when the pelvic area is involved in the treatment.

Choice D reason:
Surgical interventions to remove the cancer may be part of the treatment plan, but they do not directly address the concern of radiation-induced infertility. Surgery can also result in infertility, depending on the organs involved and the extent of the procedure.

A. Keep artificial nails trimmed. B. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile. C. Use chlorhexidine to wash hands if the client is immunosuppressed. D. Use alcohol-based hand rubs before administering eye drops for a client.

Correct Answer is C

Explanation

Choice A reason:
Keeping artificial nails trimmed is a recommended practice in healthcare settings to maintain effective hand hygiene. Long nails can harbor bacteria and make it difficult to clean hands thoroughly. However, the CDC does not provide specific guidelines on the length of artificial nails for healthcare workers.

Choice B reason:
When caring for a client with Clostridium difficile, it is recommended to wash hands with soap and water rather than using alcohol-based hand rubs. Alcohol-based hand rubs are not effective against C. difficile spores. Therefore, thorough handwashing with soap and water is necessary to remove spores.

Choice C reason:
Chlorhexidine is an antiseptic agent that provides broad-spectrum antimicrobial activity and is recommended for hand hygiene in certain situations, such as before invasive procedures or for clients who are immunosuppressed. It is effective against a wide range of bacteria, viruses, and fungi, making it a suitable choice for immunocompromised patients to reduce the risk of infection.

Choice D reason:
The use of alcohol-based hand rubs before administering eye drops is not specifically recommended. While hand hygiene is essential before any contact with a patient, there is no particular preference for alcohol-based hand rubs in this context. The primary concern is to ensure that hands are clean to prevent contamination of the eye drops or the patient's eyes.

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A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?

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