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1. Question
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
Correct
Option 3 is the correct answer.
Rationale:Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.
Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation, to assist in directing you to the correct option.
Incorrect
Option 3 is the correct answer.
Rationale:Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.
Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation, to assist in directing you to the correct option.
Thyroidectomy
Description
Removal of the thyroid gland
Performed when persistent hyperthyroidism exists
Subtotal thyroidectomy, removal of a portion of the thyroid gland, is the preferred surgical intervention.
Preoperative interventions
Obtain vital signs and weight.
Assess electrolyte levels.
Assess for hyperglycemia.
Instruct the client in how to perform coughing and deep-breathing exercises and how to support the neck in the postoperative period when coughing and moving.
Administer antithyroid medications, iodides, propranolol, and glucocorticoids as prescribed to prevent the occurrence of thyroid storm
