Medical Surgical Thyroid #2

Question

The nurse is caring for a client who has undergone subtotal thyroidectomy. Which post-operative assessment should receive the highest priority?

Answers

  1. Swallowing reflex
    • Rationale:

      This answer is correct because assessment of a client following a subtotal thyroidectomy includes assessment of anything that could be affected by edema or damage to the laryngeal nerve. The swallowing reflex is the priority to assess following subtotal thyroidectomy. Impaired swallowing may occur related to edema or laryngeal nerve damage that could result from the surgical procedure. Swallowing difficulty related to edema may also affect the airway. The nurse should assess for inspiratory stridor, respiratory difficulty, and hoarseness.

  2. Swelling in lower extremities
    • Rationale:

      This answer is not correct because swelling of the airway (not the lower extremities) and laryngeal nerve damage is the priority concern after a subtotal thyroidectomy. Therefore, the swallow reflex is the highest priority post-operative assessment.

  3. Respiratory rate of 22 breaths/min
    • Rationale:

      This answer is not correct because a respiratory rate of 22 per minute is barely over the normal of 12-20 per minute. Assessment of a client following a subtotal thyroidectomy includes assessment of anything that could be affected by edema or damage to the laryngeal nerve. The swallowing reflex is the priority to assess following subtotal thyroidectomy. Impaired swallowing may occur related to edema or laryngeal nerve damage that could result from the surgical procedure.

  4. Heart rate of 98 beats/min
    • Rationale:

      This answer is not correct because a heart rate of 98 beats per minute is not concerning because it is within the normal range of 60-100 bpm and is somewhat expected due to postoperative pain. Assessment of a client following a subtotal thyroidectomy includes assessment of anything that could be affected by edema or damage to the laryngeal nerve. The swallowing reflex is the priority to assess following subtotal thyroidectomy. Impaired swallowing may occur related to edema or laryngeal nerve damage that could result from the surgical procedure.

Overview

The highest priority postoperative subtotal thyroidectomy assessment is assessing the airway and swallowing reflex. This is due to the location of the surgery and risk for edema and laryngeal nerve damage.

Explanation

Learning Outcomes

Assessment of a client following a subtotal thyroidectomy includes assessment of anything that could be affected by edema or damage to the laryngeal nerve. The swallowing reflex is important to assess following subtotal thyroidectomy. Impaired swallowing may occur related to edema or laryngeal nerve damage that could result from the surgical procedure. Swallowing difficulty related to edema may also affect the airway. The nurse should assess for inspiratory stridor, respiratory difficulty, and hoarseness.

Test Taking Tip

If ever in doubt or unsure of an answer, consider an airway option. If there are two airway or breathing options, look to see if one is more concerning than the other and remember the airway should be considered before breathing if they seem equally concerning.

Video Rationale