What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

"This IV infusion makes me urinate more often than usual."

"I'm most comfortable when the head of the bed is raised."

"The dressing over my incision feels like it is too tight."

"When I get out of bed quickly, I feel a little dizzy."

Answer and Explanation

The Correct Answer is C

A. Increased urination due to IV fluids is common and not immediately concerning.

B. Comfort with an elevated head of bed is typical postoperatively.

C. A tight dressing could indicate swelling or a potential complication such as hematoma, which can compromise the airway and requires immediate assessment.

D. Dizziness upon standing is common and not as urgent as potential airway compromise.

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Correct Answer is C

Explanation

A. Listening for extra heart sounds, murmurs, and rhythm is important, but obtaining an ECG and starting continuous monitoring should be prioritized to assess for possible acute coronary syndrome.

B. Reducing environmental stimuli is beneficial for patient comfort but is not the immediate priority in assessing and managing potential cardiac events.

C. Obtaining a 12-lead electrocardiogram and beginning continuous cardiac monitoring are critical actions to diagnose and monitor for myocardial infarction or other cardiac events. These steps provide vital information for immediate treatment decisions.

D. Restricting family and visitors may be necessary but is not the immediate next action compared to performing an ECG and continuous monitoring to assess the client's cardiac status.

A. Restless B. Awake and alert C. Anxious D. Respiratory rate 28 breaths/minute E. Oxygen Saturation 90% on room air F. Productive cough G. Heart rate 101 beats/minute H. Capillary refill 4 seconds I. Blood pressure 145/89 mm Hg

Correct Answer is ["A","C","D","E","G"]

Explanation

Neurological: Restlessness and anxiety can both be symptoms of hypoxia due to the brain's sensitivity to changes in oxygen levels.

Respiratory: Low oxygen saturation directly indicates hypoxia, and an increased respiratory rate can be a compensatory response to low oxygen levels.

Cardiovascular: Elevated heart rate can be a compensatory mechanism for hypoxia, and delayed capillary refill may indicate poor perfusion related to low oxygen levels.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["A","C","D","E","G"]

Explanation

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

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