The nurse has reviewed the Vital Signs at 1000.
For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.
Administer aspirin for fever
Apply cooling blanket
Monitor vital signs every 4 hours
Place client on telemetry
Palpate thyroid area to assess for hematoma
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.
• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.
• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.
• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.
• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Anuria: Anuria, or the absence of urine output, indicates severe dehydration or acute renal failure rather than moderate dehydration. Moderate dehydration usually presents with decreased but not absent urine output, as the body still tries to conserve fluids.
B. A 7% weight loss from baseline: A weight loss of 6% to 9% of body weight is consistent with moderate dehydration in infants and children. This measurable sign is a critical and objective indicator used to assess the severity of dehydration, particularly following prolonged vomiting or diarrhea.
C. Hyperpnea: Hyperpnea, or abnormally deep and rapid breathing, can be seen in cases of severe dehydration or metabolic acidosis. It is not a classic finding of moderate dehydration, where respiratory patterns are usually normal or only mildly affected.
D. Lethargy: Lethargy typically suggests severe dehydration rather than moderate. In moderate dehydration, the infant may be irritable or thirsty but usually maintains normal mental status without profound decreases in responsiveness or alertness.
Correct Answer is C
Explanation
A. Dry excess sanitizer from hands with a paper towel: Hand sanitizer should be allowed to dry naturally, and there is no need to wipe it off with a paper towel. Wiping off the sanitizer could reduce its effectiveness in killing germs.
B. Rubs hands together for 10 seconds after applying sanitizer: The Centers for Disease Control and Prevention (CDC) recommends rubbing hands together for at least 20 seconds to ensure that the hand sanitizer covers all surfaces of the hands and effectively kills germs.
C. Apply enough sanitizer to completely cover both hands: It is important to apply a sufficient amount of hand sanitizer (usually about a dime-sized amount) to cover both hands entirely. The sanitizer should be rubbed into all areas of the hands, including between fingers and under nails, until the hands are dry.
D. Clean sanitizer from under fingernails using an orangewood stick: This is unnecessary if the sanitizer is applied properly and rubbed in completely. Hand sanitizer should be used to cover all areas of the hands, including under fingernails, and should be allowed to dry naturally without needing to clean it with a stick.
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