The nurse is caring for a client who has just returned to the unit following a thyroidectomy. Which assessment finding is a priority for the nurse to report to the healthcare provider?
Oral temperature of 99.8°F (37.7°C)
Post-operative hemoglobin of 10.9 g/dL (normal range: 12-16 g/dL)
Client report of pressure sensation at the incision site
Client report of 5/10 pain at the incision site
The Correct Answer is C
Choice A reason: An oral temperature of 99.8°F (37.7°C) post-operatively may not be unusual and does not necessarily indicate a complication.
Choice B reason: A post-operative hemoglobin of 10.9 g/dL is slightly below the normal range but may be expected after surgery due to blood loss.
Choice C reason: A client reporting a pressure sensation at the incision site could indicate bleeding or swelling under the incision, which can be a sign of a hematoma, a serious complication that needs immediate attention.
Choice D reason: Pain at the incision site is expected post-operatively and can be managed with pain relief measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering oxygen via mask is appropriate for a client with sepsis who may have compromised oxygenation.
Choice B reason: Obtaining a serum lactate level is important in sepsis as it can indicate the severity of the condition and guide treatment.
Choice C reason: An infusion rate of 0.9% Normal Saline at 50 mL/hr may be questioned because clients with sepsis may require more aggressive fluid resuscitation.
Choice D reason: Obtaining blood and urine cultures is essential before starting antibiotics to identify the causative organism in sepsis.
Correct Answer is D
Explanation
Choice A reason: Petechiae and bruising could be related to low platelet counts or clotting issues, but they are not directly indicated by the provided lab values.
Choice B reason: Jaundice and pruritus are symptoms associated with liver disease but are not specifically indicated by the lab values provided.
Choice C reason: Dyspnea and fatigue could be symptoms of many conditions, including liver disease, but they are not directly indicated by the lab values provided.
Choice D reason: Asterixis, a flapping tremor of the hands, and confusion are signs of hepatic encephalopathy, which can be associated with elevated serum ammonia levels, as indicated by the lab results.
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