Hurst 3 Study Guide.

Hurst 3 Study Guide. The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers - CORRECT ANSWER Correct: One potential risk during a thyroidectomy is the accidental removal of some or all of the parathyroid glands. The client would develop signs and symptoms of hypocalcemia from decreased blood levels of calcium. As muscles become rigid and twitch, the resulting tetany would cause the client to experience a tingling sensation in toes and fingers. The nurse needs to notify the primary healthcare provider so that a calcium level can be drawn and the client given supplemental calcium. 1. Incorrect: Following a transurethral resection of the prostate (TURP), it is normal for urine to be cherry red in color. Continuous bladder irrigation will keep clots from developing over several days and the deep red color of urine is an expected finding following this procedure. 2. Incorrect: Mastectomy clients return from surgery with one or more drains placed under skin flaps in the breast tissue. These drains are part of a collection system that allows serous drainage to be removed from the surgical site, thus enhancing the healing process. Because this client has just returned from surgery, 40 mL over 3 hours is not an excessive amount. This is an expected finding that does not need to be reported. 3. Incorrect: The sign of a healthy stoma immediately post-op is a beefy red appearance and slightly elevated above the level of the abdomen. It is expected that the stoma will have a mucoid discharge for a day or so until normal stool begins to form again. This client displays normal post-operative findings with nothing unexpected. What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry. - CORRECT ANSWER 1., 2., 3., & 4. Correct: Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury such as a pin prick or sunburn can cause painful swelling after lymph node removal. 5. Incorrect: The client may wear jewelry that does not inhibit lymph drainage. They should avoid jewelry that constricts the affected arm.