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","D","E"]
Explanation
Rationale:
A. Bradycardia is not typically associated with emphysema; tachycardia is more common due to hypoxia.
B. Deep respirations are not a hallmark of emphysema; patients often have shallow, rapid breathing due to decreased lung capacity.
C. A barrel chest is a characteristic sign of emphysema, resulting from hyperinflation of the lungs over time.
D. Clubbing of the fingers can occur due to chronic hypoxia associated with emphysema.
E. Dyspnea, or difficulty breathing, is a primary symptom of emphysema due to the destruction of alveoli and reduced gas exchange.
Correct Answer is A
Explanation
Rationale:
A. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.
B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.
C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.
D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.