A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Place the head of the client's bed in the flat position.

Instruct the client to deep breathe every 4 hr.

Hyperextend the client's neck.

Check the client's voice every 2 hr.

Answer and Explanation

The Correct Answer is D

- Choice A Rationale: Placing the head of the bed in the flat position is not recommended as it can increase the risk of airway obstruction and reduce venous drainage from the head, which is especially critical after thyroid surgery.
- Choice B Rationale: While deep breathing is important postoperatively, it is not specific to thyroidectomy care and should be done more frequently than every 4 hours to ensure adequate ventilation and prevent atelectasis.
- Choice C Rationale: Hyperextending the client's neck can be harmful post-thyroidectomy as it may put stress on the surgical site, potentially leading to dehiscence or damage to the area.
- Choice D Rationale: Checking the client's voice every 2 hours is essential after a thyroidectomy because vocal cord paralysis can be an indicator of recurrent laryngeal nerve damage, which is a potential complication of the surgery. Monitoring the voice allows for early detection and intervention.

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Correct Answer is B

Explanation

A. Obtaining a culture of the drainage may be necessary, but the immediate concern is to determine if the drainage is cerebrospinal fluid (CSF) or another type of fluid. Checking for glucose content is a rapid way to differentiate CSF from other fluids.

B. Correct. Clear drainage from the nose post-transsphenoidal hypophysectomy may indicate a CSF leak, which is a potential complication. Checking the drainage for glucose can help differentiate CSF from other fluids, as CSF contains glucose. If the drainage tests positive for glucose, it indicates the presence of CSF.

C. Documenting the amount of drainage is important, but determining the nature of the drainage (CSF or other fluid) takes precedence in this situation.

D. Notifying the client's provider is important, but the nurse should gather information about the drainage first by checking for glucose content. This information will be crucial for the healthcare provider to make decisions about further interventions

A. Palpitations B. Diaphoresis C. Exophthalmos D. Weight gain

Correct Answer is D

Explanation

A. Incorrect. Palpitations, which are rapid or irregular heartbeats, are more commonly associated with hyperthyroidism, where there is an excess of thyroid hormones.

B. Incorrect. Diaphoresis, or excessive sweating, is not typically associated with hypothyroidism.

C. Incorrect. Exophthalmos, or bulging of the eyes, is a characteristic finding in hyperthyroidism (specifically Graves' disease) and is not typically seen in hypothyroidism.

D. Correct. Weight gain is a common finding in hypothyroidism. The slowing down of metabolic processes due to insufficient thyroid hormones can lead to an increase in body weight.

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A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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