A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Airway patency
Temperature
Pain control
Urination
The Correct Answer is A
Rationale:
A. Airway patency is the highest priority following a thyroidectomy due to the risk of airway obstruction from swelling or hematoma formation near the surgical site. Compromised airway can lead to respiratory distress and requires immediate attention.
B. While monitoring temperature is important for detecting potential infections, it is not the immediate priority.
C. Pain control is important for comfort and recovery, but it is not life-threatening.
D. Urination should be monitored postoperatively, but it is not as critical as ensuring a patent airway.
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Correct Answer is D
Explanation
Rationale:
A. Hypertension can be a symptom of many conditions and is not specific to HHS.
B. Fruity breath is typically associated with diabetic ketoacidosis (DKA) due to the presence of acetone, not HHS.
C. Ketosis is a key feature of DKA, not HHS. In HHS, ketosis is usually absent or minimal.
D. A glucose level of 650 mg/dL is indicative of HHS, which is characterized by extremely high blood glucose levels without significant ketosis. HHS often occurs in type 2 diabetes and is marked by severe hyperglycemia, dehydration, and altered mental status.
Correct Answer is D
Explanation
Rationale:
A. Levofloxacin is an antibiotic used to treat bacterial infections, not hypothyroidism.
B. Radioactive iodine is used to treat hyperthyroidism by reducing thyroid hormone production, not hypothyroidism.
C. Sumatriptan is a medication used to treat migraines, not hypothyroidism.
D. Levothyroxine is the standard treatment for hypothyroidism. It is a synthetic form of the thyroid hormone thyroxine (T4) and helps to normalize thyroid function by supplementing the hormone that the thyroid gland is not producing adequately.