Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?
A. Neck stiffness
Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness
Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Moderate serosanguineous drainage
Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching
Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.
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Full Explanation
Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A. Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.
Similar Questions
A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?
A. Receiving bronchodilator medication
B. Weight loss of 2.8 kg (6.2 b)
Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable. Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown
C. Hemoglobin 17 g/dl (12 to 16 g/dL)
D. Wearing an oxygen device
Full Explanation
Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.
Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown
A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?
A. Monitor vital signs at least every 4 hr.
Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Insert an indwelling urinary catheter.
Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Change the client's linens three times a day.
Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Place the client in a room with negative airflow.
Clients should be placed in a positive airflow room to prevent contracting infections from infected persons
Full Explanation
A. Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Clients should be placed in a positive airflow room to prevent contracting infections from infected persons
A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?
A. Hgb 18 g/dL (12 to 16 g/dl)
B. WBC 12.000/mm3 (5,000 to 10,000/mm3)
C. 25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL)
D. Albumin 3.1 g/dL (3.5 to 5 g/dL)
Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability. Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.
Full Explanation
Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability.
Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.