The nurse is caring for a client after a total thyroidectomy. The nurse's priority should be to:
Encourage the client to cough and deep breathe every two hours, with her neck in a flexed position.
Maintain the client in a Fowler's position, with head neutral supported by pillows.
Maintain the client in a supine position, with sandbags placed on either side of her head and neck.
Encourage the client to turn head side to side, to promote drainage of oral secretions.
The Correct Answer is B
Choice A Reason: Encouraging the client to cough and deep breathe every two hours, with her neck in a flexed position, is not a priority for a client after a total thyroidectomy, as it may increase the risk of bleeding or damage to the surgical site.
Choice B Reason: Maintaining the client in a Fowler's position, with head neutral supported by pillows, is a priority for a client after a total thyroidectomy, as it helps to reduce swelling and edema, prevent airway obstruction, and promote venous drainage.
Choice C Reason: Maintaining the client in a supine position, with sandbags placed on either side of her head and neck, is not a priority for a client after a total thyroidectomy, as it may impair breathing and circulation, increase pressure on the surgical site, and cause neck stiffness.
Choice D Reason: Encouraging the client to turn head side to side, to promote drainage of oral secretions, is not a priority for a client after a total thyroidectomy, as it may cause pain and discomfort, disrupt the sutures or drains, and increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Anorexia is not a symptom of hypoglycemia, but it may indicate a loss of appetite due to other causes such as nausea, infection, or depression.
Choice B Reason: Warm skin is not a symptom of hypoglycemia, but it may indicate a fever, inflammation, or infection.
Choice C Reason: Fruity breath is not a symptom of hypoglycemia, but it may indicate ketoacidosis, which is a serious complication of hyperglycemia.
Choice D Reason: Nervousness is a symptom of hypoglycemia, as the low blood glucose level affects the brain and causes anxiety, irritability, confusion, and tremors.
Correct Answer is D
Explanation
Choice A Reason: Loss of erythropoietin will not result in diminished immunologic function, but it may affect the production of some white blood cells and antibodies.
Choice B Reason: Loss of erythropoietin will not result in hypertension, but it may cause hypotension due to reduced blood volume and viscosity.
Choice C Reason: Loss of erythropoietin will not result in elevated lipid levels in the bloodstream, but it may be associated with dyslipidemia due to other factors such as malnutrition, inflammation, or medication use.
Choice D Reason: Loss of erythropoietin will result in anemia, as erythropoietin is a hormone that stimulates the bone marrow to produce red blood cells.
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