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Adult Health Exam 1 Chamberlain

The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?

    A. Hoarseness of the voice.

    B. Slight swelling at the incision site.

    C. Tingling around the mouth.

    D. Mild fever.

Correct Answer: C
Rationale: Tingling around the mouth should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.

The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?

  • A. Hoarseness of the voice.
  • B. Slight swelling at the incision site.
  • C. Tingling around the mouth.
  • D. Mild fever.

Correct Answer: C
Rationale: Tingling around the mouth should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.

The nurse is caring for a client postoperatively following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?

  • A. Keep the client in a low Fowler's position
  • B. Maintain hip abduction with pillows
  • C. Encourage early ambulation
  • D. Place the client in a prone position

Correct Answer: B
Rationale: Maintaining hip abduction with pillows is crucial in preventing dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and reduces the risk of the prosthesis becoming displaced. Choices A, C, and D are not as effective in preventing dislocation. Keeping the client in a low Fowler's position does not provide the necessary hip support. While early ambulation is important for circulation and preventing complications, maintaining hip abduction is more specific to preventing prosthesis dislocation. Placing the client in a prone position can increase the risk of hip prosthesis dislocation due to the extreme positioning.

The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?

  • A. Notify the anesthesiologist
  • B. Document the intake in the medical record
  • C. Cancel the surgery
  • D. Instruct the client to fast until the surgery

Correct Answer: A
Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.

The nurse is assessing a client with an IV infusion of normal saline. The client reports pain and swelling at the IV site. What should the nurse do first?

  • A. Slow the rate of infusion
  • B. Apply a warm compress to the site
  • C. Elevate the affected arm
  • D. Discontinue the IV infusion

Correct Answer: D
Rationale: The correct answer is to discontinue the IV infusion. Pain and swelling at the IV site may indicate infiltration or phlebitis, which requires immediate discontinuation of the infusion to prevent further complications. Continuing the infusion can lead to tissue damage or infection. Slowing the rate of infusion, applying a warm compress, or elevating the affected arm would not address the underlying issue of infiltration or phlebitis and could potentially worsen the condition by allowing more fluid to infiltrate the tissues.

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