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 C
Explanation
Rationale:
A. Moist mucous membranes would indicate adequate hydration, which is not typically seen in diabetes insipidus.
B. Bounding peripheral pulses are associated with conditions of fluid overload, not diabetes insipidus.
C. Poor skin turgor is a sign of dehydration, which is a common finding in diabetes insipidus due to excessive urine output leading to significant fluid loss.
D. Bradycardia is not typically associated with diabetes insipidus; tachycardia might be seen due to dehydration and hypovolemia.
Correct Answer is D
Explanation
Rationale:
A. A low temperature is not indicative of organ rejection; fever would be more concerning.
B. Weight loss is not a typical sign of acute organ rejection; weight gain due to fluid retention might be observed.
C. Insomnia is not specifically associated with organ rejection.
D. Oliguria (decreased urine output) is a significant sign of possible kidney transplant rejection, as it may indicate impaired kidney function.