Author Question: The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate ... (Read 108 times)

Tazate · **on:** Jun 25, 2018

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to

a. protect the patient's skin.
b. monitor for signs of infection.
c. balance fluids and electrolytes.
d. prevent emotional disturbances.

Question 2

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first?

a. Observe the dressing for bleeding.
b. Check the blood pressure and pulse.
c. Assess the patient's respiratory effort.
d. Support the patient's head with pillows.

CharlieArnold · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

Answer to Question 2

ANS: C
Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.