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NurseDive Free Nursing Practice Question
A nurse is caring for a client on a medical-surgical unit.
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. Click to highlight the findings below that the nurse should report to the provider.
Nurses Notes
Oxygen saturation 95%
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
A. The client's voice is hoarse.
None
B. The client reports tingling around the mouth
None
C. Moderate serosanguinous drainage noted on neck dressing.
None
D. The client has a slight tremor noted in both hands.
None
E. The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
None
F. The client appears restless
None
G. Oxygen saturation 95%
None
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Proctored Exam 8. Take the full exam now
Full Explanation
The nurse should report the hoarseness of the client's voice, which could indicate recurrent laryngeal nerve damage, which is a risk associated with thyroid surgery. Tingling around the mouth may suggest hypocalcemia, a common complication after thyroidectomy due to accidental removal or damage to the parathyroid glands. The moderate serosanguinous drainage on the neck dressing could signify bleeding or infection, which requires immediate attention. The noted tremor in both hands and the increase in temperature could be signs of a thyroid storm, a rare but life-threatening condition.
Furthermore, the client's restlessness could be a response to discomfort or could indicate a more serious issue, such as an impending thyrotoxic crisis. Oxygen saturation at 95% is within normal limits postoperatively; however, it should be monitored closely.
Similar Questions
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
A. Urine output of 50 mL in 4hr
A urine output of 50 mL in 4 hours is inadequate and may indicate decreased renal perfusion. Magnesium sulfate can further compromise renal perfusion, so this finding warrants careful evaluation and potential adjustment of the infusion rate.
B. Respiratory rate of 16/min
This indicates that the client is not experiencing respiratory depression, a potential side effect of magnesium sulfate toxicity.
C. Diminished deep tendon reflexes
Diminished deep tendon reflexes is an expected finding in magnesium sulfate toxicity.
D. Heart rate of 56/min
A heart rate of 56/min is below the normal range for an adult but may be a common finding in clients receiving magnesium sulfate due to its cardiac depressant effects.
Full Explanation
A. A urine output of 50 mL in 4 hours is inadequate and may indicate decreased renal perfusion. Magnesium sulfate can further compromise renal perfusion, so this finding warrants careful evaluation and potential adjustment of the infusion rate.
B. This indicates that the client is not experiencing respiratory depression, a potential side effect of magnesium sulfate toxicity.
C. Diminished deep tendon reflexes is an expected finding in magnesium sulfate toxicity.
D. A heart rate of 56/min is below the normal range for an adult but may be a common finding in clients receiving magnesium sulfate due to its cardiac depressant effects.
A nurse is assessing four clients on a medical unit. The nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism?
A. A client who has muscle hypertrophy.
Muscle hypertrophy is not a typical manifestation of hypercortisolism; rather, muscle weakness and wasting may occur.
B. Moon face
Moon face, or rounded facial appearance with prominent cheeks, is a characteristic manifestation of hypercortisolism (Cushing's syndrome).
C. A client who has a butterfly rash on his face.
A butterfly rash on the face is not specific to hypercortisolism; it may suggest other conditions such as systemic lupus erythematosus.
D. A client who has a positive Chvostek's sign.
Chvostek's sign is associated with hypocalcemia, not hypercortisolism.
Full Explanation
A. Muscle hypertrophy is not a typical manifestation of hypercortisolism; rather, muscle weakness and wasting may occur.
B. Moon face, or rounded facial appearance with prominent cheeks, is a characteristic manifestation of hypercortisolism (Cushing's syndrome).
C. A butterfly rash on the face is not specific to hypercortisolism; it may suggest other conditions such as systemic lupus erythematosus.
D. Chvostek's sign is associated with hypocalcemia, not hypercortisolism.
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
A. 0.45% sodium chloride
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
B. Dextrose 10% in water
Dextrose 10% in water is hypertonic and not appropriate for a client with hypernatremia, as it could exacerbate the imbalance.
C. Lactated Ringer's
Lactated Ringer's is isotonic and contains sodium in a similar concentration to serum levels, hence it could further increase the sodium levels.
D. Dextrose 5% in 0.9% sodium chloride
Dextrose 5% in 0.9% sodium chloride (also known as D5NS) is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
Full Explanation
A. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
B. Dextrose 10% in water is hypertonic and not appropriate for a client with hypernatremia, as it could exacerbate the imbalance.
C. Lactated Ringer's is isotonic and contains sodium in a similar concentration to serum levels, hence it could further increase the sodium levels.
D. Dextrose 5% in 0.9% sodium chloride (also known as D5NS) is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.