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. While administering oxygen can help with overall oxygenation, it does not specifically address the issue of thick, tenacious secretions.
B. A low-salt diet might be indicated for other health concerns but does not directly impact bronchial secretions.
C. Semi-Fowler's position can help with lung expansion and ease of breathing but does not directly assist with loosening secretions.
D. Drinking 2 to 3 liters of water daily helps to thin bronchial secretions, making it easier for the client to expectorate (cough up) the mucus, which is particularly important in managing COPD.
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.