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 C
Explanation
Choice A Reason: Lantus is not a type of insulin that can treat this client, as it is a long-acting insulin that has no peak effect and lasts for 24 hours.
Choice B Reason: NPH is not a type of insulin that can treat this client, as it is an intermediate-acting insulin that peaks in 6 to 8 hours and lasts for 12 to 18 hours.
Choice C Reason: Regular is a type of insulin that can treat this client, as it is a short-acting insulin that peaks in 2 to 4 hours and lasts for 6 to 8 hours. It can be used to correct high blood glucose levels and treat diabetic ketoacidosis (DKA), which is indicated by confusion, flushing, and acetone breath.
Choice D Reason: Lispro is not a type of insulin that can treat this client, as it is a rapid-acting insulin that peaks in 30 minutes and lasts for 3 to 5 hours. It can be used to cover meals or snacks but not to treat DKA.
Correct Answer is D
Explanation
Choice A Reason: Administering antispasmodic medications is not the first action that the nurse should perform, as it may not resolve the problem of urinary output or irrigation flow.
Choice B Reason: Notifying the provider is not the first action that the nurse should perform, as it may delay the intervention and worsen the outcome.
Choice C Reason: Offering oral fluids is not the first action that the nurse should perform, as it may increase fluid overload or bladder pressure.
Choice D Reason: Determining the patency of the tubing is the first action that the nurse should perform, as it may identify and correct any obstruction or kinking that prevents urinary output or irrigation flow.
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