Medical Surgical Thyroid #7

Question

The nurse receives a client from the 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:

      This answer is correct because after a thyroidectomy, the nurse must assess for signs of tetany secondary to risk for parathyroid injury and should keep calcium gluconate for parenteral use nearby. Calcium levels can plummet, causing severe tetany and life-threatening airway compromise.

  2. Assess back of neck
    • Rationale:

      This answer is correct because after a thyroidectomy 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.

  3. Have tracheostomy set-up nearby
    • Rationale:

      This answer is correct because after a thyroidectomy edema can occur and calcium levels can plummet, causing life-threatening airway compromise. Nurses must assess airway obstruction from postoperative edema and tracheostomy and airway measures must be available for such an emergency.

  4. Ambulate within 4 hours
    • Rationale:

      This answer is not correct because ambulation is not a priority intervention during the immediate postoperative period. The immediate postoperative time after a thyroidectomy is critical. 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. Nurses must assess airway obstruction from postoperative edema and tracheostomy and airway measures must be available for such an emergency.

  5. Assess the client's respiratory rate and rhythm
    • Rationale:

      This answer is correct because an increase in respiratory rate is an early indicator of post-op edema or hematoma formation in the upper airways. Keeping the head elevated to 45 degrees and utilizing an ice collar are interventions to help decrease edema.

Overview

The priority post-operative care for a client following a thyroidectomy includes assessing for bleeding at the back of the neck and keeping IV 10% calcium gluconate and tracheostomy supplies nearby.

Explanation

Learning Outcomes

The immediate postoperative time after a thyroidectomy is critical. Astute nursing assessment is imperative. After a 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. Nurses must assess airway obstruction from postoperative edema and tracheostomy and airway measures must be available for such an emergency.

Test Taking Tip

Remembering the ABCs of nursing will help you determine the answers to post-op care in general, but administration of calcium is unique to this situation. Understanding the anatomy of the thyroid and parathyroids will help with understanding the importance and need to have calcium available after a complete thyroidectomy.

Video Rationale