Nokea
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
- A. Indwelling urinary catheter kit
- B. Cardiac monitor
- C. Tracheostomy set
- D. Humidifier
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set
Rationale:
1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway.
2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention.
3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment.
Summary of other choices:
A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care.
B: Cardiac monitor - Important but secondary to airway management in this situation.
D: Humidifier - Not essential for immediate post-thyroidectomy care.
You may also like to solve these questions
Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure.
A: The nurse taking the temperature in different positions is not directly related to assessing hypertension.
C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension.
D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.
A surgical intervention that can cause substantial remission of myasthenia gravis is:
- A. Esophagostomy
- B. Thymectomy
- C. Myomectomy
- D. Spleenectomy
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. The thymus gland is often found to be abnormal in individuals with myasthenia gravis, and removing it through thymectomy can lead to substantial remission of symptoms. This is because the thymus plays a role in the development of the immune system and may be producing antibodies that attack neuromuscular junctions in myasthenia gravis.
Choice A, esophagostomy, is a surgical procedure to create an opening in the esophagus for feeding and has no direct impact on myasthenia gravis. Choice C, myomectomy, is the removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, spleenectomy, is the removal of the spleen and is not a treatment for myasthenia gravis as the spleen is not implicated in the disease process.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This includes collecting subjective and objective data to form a baseline for further decision-making. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining outcomes (D) is done in the final phase (evaluation). Therefore, completing a comprehensive database is the most appropriate action in the first phase.
A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hypercalcemia
- D. Hypochloremia
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood.
Incorrect choices:
A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia.
B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia.
D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
- A. Extremities
- B. Head
- C. Eyeball
- D. Chest and nostrils A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET L
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.