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","C","D","E"]
Explanation
Rationale:
A. Reducing cholesterol and saturated fat intake is important for managing cardiovascular health, which is crucial for clients with diabetes to prevent complications such as heart disease and stroke.
B. Sustaining hyperglycemia is incorrect; it actually contributes to complications like neuropathy, retinopathy, and nephropathy. The goal is to maintain blood glucose levels within the target range.
C. Maintaining optimal blood pressure is essential in preventing diabetic nephropathy, as high blood pressure can damage the kidneys and worsen diabetic kidney disease.
D. Increasing physical activity helps improve insulin sensitivity, control blood glucose levels, and reduce the risk of complications associated with diabetes.
E. Smoking cessation is critical in reducing the risk of cardiovascular disease, which is higher in clients with diabetes. Smoking can exacerbate the complications of diabetes.
Correct Answer is B
Explanation
Rationale:
A. Bubbling in the water seal chamber with exhalation can be normal as it indicates air is escaping from the pleural space; however, continuous bubbling may indicate an air leak and would need to be assessed.
B. Movement of the trachea toward the unaffected side is a sign of a tension pneumothorax, a life-threatening condition requiring immediate
medical intervention. This tracheal deviation suggests that the pressure in the pleural space is increasing, pushing the mediastinum to the opposite side.
C. Scant serosanguinous drainage on the dressing is expected and not an immediate concern unless it becomes excessive.
D. Crepitus, or subcutaneous emphysema, indicates air leakage into the tissues but is not immediately life-threatening unless it is extensive and worsening rapidly.