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 A
Explanation
Rationale:
A. It is essential to keep the drainage system below the level of the client's chest to prevent backflow of fluid into the pleural space, which could lead to complications such as a pneumothorax.
B. Clamping the chest tube is generally not recommended during transport because it can lead to a buildup of pressure in the pleural space, increasing the risk of a tension pneumothorax.
C. Disconnecting the chest tube from the drainage system is not advisable, as this could lead to air entering the pleural space, causing a pneumothorax.
D. Emptying the collection chamber is not necessary prior to transport, and it could lead to inaccurate measurement of fluid output. The focus should be on ensuring that the system remains intact and below chest level during transport.
Correct Answer is A
Explanation
Rationale:
A. Desmopressin is a synthetic analog of antidiuretic hormone (ADH) and is used to reduce urine output in conditions like diabetes insipidus. Monitoring urine output is the primary way to assess the effectiveness of this medication. A decrease in urine volume indicates the medication is working effectively.
B. Pupillary response is not relevant in assessing the effectiveness of desmopressin.
C. Temperature monitoring is important in general patient care but does not directly relate to the effectiveness of desmopressin.
D. Apical heart rate is important to monitor in many scenarios but is not a direct indicator of desmopressin's effectiveness.