Mrs. H, who has just had a thyroidectomy, is complaining of a sore throat and difficulty swallowing. What is the most appropriate action for the nurse to take?

Correct Answer: D

Rationale: The correct answer is D) Assess the surgical site for signs of bleeding or hematoma formation. Rationale: After a thyroidectomy, sore throat and difficulty swallowing can indicate potential complications such as bleeding or hematoma formation, which can compromise the patient's airway and require immediate intervention. Assessing the surgical site is crucial to identify any signs of bleeding or hematoma early on. This action is essential for the nurse to ensure prompt detection and management of any postoperative complications, preventing further harm to the patient. Why the others are wrong: A) Administering analgesics and reassuring the patient may provide temporary relief but does not address the underlying issue of potential bleeding or hematoma. B) Calling the surgeon immediately is important in some situations, but the nurse should first assess the patient's condition to provide accurate information to the surgeon. C) Deep breathing and coughing exercises are not appropriate in this scenario as they do not address the specific concerns related to sore throat and difficulty swallowing post-thyroidectomy. Educational context: This question highlights the importance of postoperative assessment and early recognition of complications following a thyroidectomy. Nurses need to be vigilant in monitoring patients for signs of bleeding or hematoma formation, as prompt intervention can be life-saving. Understanding the potential complications of thyroidectomy and knowing how to respond appropriately are critical skills for nurses caring for patients undergoing this procedure.

Correct Answer: C

Rationale: The correct answer is C) Pulmonary congestion. Explanation: Fluid overload is a condition characterized by an excess of fluid in the body, often due to issues with the heart, kidneys, or liver. Pulmonary congestion is a common sign of fluid overload, where fluid accumulates in the lungs leading to symptoms like shortness of breath, coughing, and crackles heard on auscultation. This occurs because the excess fluid leaks into the lungs from the congested blood vessels. Weakness (Option A) and headache (Option B) are not typical signs of fluid overload. Weakness may result from various causes such as electrolyte imbalances or anemia, while headaches can be due to migraines, tension, or other causes unrelated to fluid overload. Weight gain without edema (Option D) is a tricky distractor as it may seem related to fluid overload. However, in fluid overload, weight gain is usually accompanied by edema (swelling) due to the accumulation of fluid in the interstitial spaces. Weight gain without edema may point towards other reasons like increased calorie intake or decreased physical activity. Educational Context: Understanding the signs of fluid overload is crucial in healthcare, especially for nurses, physicians, and other healthcare providers. Recognizing these signs promptly can help in early intervention and appropriate management of patients with fluid overload, preventing complications such as pulmonary edema and heart failure exacerbation. This knowledge is essential in various clinical settings, including hospitals, clinics, and long-term care facilities.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D - "Monitor lying and standing blood pressure every 4 hours with cuff placed on the same arm." This task can be appropriately delegated to a nursing assistant because it involves routine monitoring that does not require specialized nursing judgment. Monitoring blood pressure in different positions is crucial in assessing for orthostatic hypotension, a common complication post-adrenalectomy in patients with pheochromocytoma. Option A is incorrect because adding strategies to provide a calm and restful environment post-operatively requires nursing knowledge and critical thinking to individualize care based on the patient's condition and needs. Option B is incorrect as warning the patient to avoid smoking and caffeinated beverages involves patient education and counseling, which should be done by a licensed healthcare provider. Option C is also incorrect as monitoring the patient's skin and mucous membranes for signs of hydration requires assessment skills to interpret the findings correctly. Educationally, it is important to understand the principles of delegation in nursing practice. Delegating tasks appropriately ensures efficient patient care while promoting the professional growth and development of all team members. Understanding which tasks can be delegated to nursing assistants versus those that require a higher level of expertise is essential for providing safe and effective care to patients.

Correct Answer: D

Rationale: The correct answer is D) "I will gradually wean myself off the vasopressin." This statement indicates a need for additional teaching because patients with diabetes insipidus (DI) require vasopressin replacement therapy for life due to their inability to produce sufficient antidiuretic hormone. Weaning off vasopressin can lead to life-threatening dehydration and electrolyte imbalances in DI patients. Option A is correct as it demonstrates an understanding of the need to maintain fluid balance by matching urine output with fluid intake. Option B is also correct as daily weight monitoring helps in assessing fluid status changes in DI patients. Option C is important for emergency identification in case the patient is unable to communicate their condition. In an educational context, it's crucial for healthcare providers to emphasize the lifelong nature of vasopressin replacement therapy in DI patients. Patients should be educated on signs of dehydration, the importance of consistent medication adherence, and the necessity of wearing medical alert jewelry to ensure proper management of their condition and prevent serious complications.