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. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.
Correct Answer is C
Explanation
Rationale:
A. Assisting the client to the bathroom might be helpful, but it is not the first action the nurse should take since the client hasn't voided for an extended period.
B. Increasing fluids may be beneficial but does not address the immediate concern of whether there is a problem with urinary retention.
C. Performing a bladder scan is the first action to determine if there is urine retention in the bladder. This information is crucial before deciding on further interventions, such as catheterization.
D. Inserting a straight catheter may be necessary if significant urinary retention is confirmed, but it should not be the first action without knowing the bladder's status.