Endocrine Question #11

Question

The nurse receives a client from recovery room after having a thyroidectomy. What most important interventions will the nurse perform during the next four hours? (Select all that apply)

Answers

  1. Keep 10% calcium gluconate available
    • Rationale:
  2. Assess back of neck
    • Rationale:
  3. Have tracheostomy set-up nearby
    • Rationale:
  4. Ambulate within 4 hours
    • Rationale:

Overview

Explanation

After thyroidectomy the nurse must assess for signs of tetany secondary to risk for parathyroid injury and should keep calcium gluconate for parenteral use nearby. The nurse must assess the back of the neck for wetness to dressing, which may indicate bleeding. Bleeding may occur from the thyroid area and flow towards the back of the neck. Nurse must assess for airway obstruction from postoperative edema and tracheostomy and airway measures must be readied for such an emergency. Ambulation within 4 hours is not a priority intervention during the immediate post-op period.

Learning Outcomes

Test Taking Tip

Video Rationale