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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Hyperplasia is an increase in the number of cells in an organ or tissue, which can lead to its enlargement. While hyperplasia can be a response to a stimulus and is not necessarily precancerous, it does not describe the abnormal changes in the shape, size, and organization of mature cells.
Choice B reason:
Metaplasia is a reversible change in which one differentiated cell type is replaced by another cell type. This process can be a response to chronic irritation and inflammation, and while it may predispose cells to cancerous changes, it is not in itself a precancerous condition.
Choice C reason:
The term 'malignant' refers to cancerous cells that have the ability to invade and destroy nearby tissue and spread to other parts of the body. The description of the cells as 'moderately abnormal' does not indicate that the cells are malignant but rather that they are showing signs of potentially precancerous changes.
Choice D reason:
Dysplasia refers to the presence of abnormal cells within a tissue or organ. It is characterized by changes in cell size, shape, uniformity, arrangement, and structure, particularly when such changes are strongly suggestive of developing neoplasia, or new, abnormal growth. In the context of a Pap smear, dysplasia is indicative of precancerous changes and is the term used to describe the abnormal development of cells on the cervix.
Correct Answer is C
Explanation
Choice A reason:
Adjusting the rate of the bladder irrigant may be necessary if there is an issue with the flow or the amount of fluid, but it is not the first action to take. The nurse must first ensure that there is no mechanical obstruction causing the lack of drainage.
Choice B reason:
Irrigating the catheter could be the next step if checking the tubing does not resolve the issue. However, it is not the first action to take because if there is a kink in the tubing, irrigation will not be effective and could potentially cause harm.
Choice C reason:
The first action the nurse should take is to check the tubing for kinks because this is a common and easily correctable cause of obstruction in catheter drainage. If the tubing is kinked, straightening it may allow urine to drain properly.
Choice D reason:
Notifying the provider is important if the other interventions do not resolve the issue. However, it is not the first action to take. The nurse should first perform basic troubleshooting steps to identify and correct any simple mechanical issues with the catheter system.
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