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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
A. A decreased level of consciousness is a common symptom of ARF due to hypoxemia, which reduces oxygen delivery to the brain, leading to confusion, agitation, or lethargy.
B. Hypercarbia, or elevated levels of carbon dioxide (CO2) in the blood, occurs due to impaired gas exchange in ARF, which leads to respiratory acidosis.
C. Severe dyspnea, or difficulty breathing, is a hallmark symptom of ARF as the lungs fail to maintain adequate oxygenation or ventilation.
D. Nausea is not a typical manifestation of ARF; while it may occur due to other factors, it is not directly associated with respiratory failure.
E. Tachycardia, or an increased heart rate, is often seen in ARF as the body attempts to compensate for hypoxemia by increasing cardiac output to deliver more oxygen to tissues.
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.