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. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.
B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.
C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.
D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.
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.