Question

The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery?

A) Assess for signs of hemorrhage or airway obstruction.
B) Encourage neck flexion exercises to prevent stiffness.
C) Provide a high-protein diet to promote healing.
D) Administer thyroid replacement hormones.

Answer 1

The nurse should prioritize assessing for signs of hemorrhage or airway obstruction in the first four hours after a thyroidectomy, due to potential complications arising from the surgery and the effects of general anesthesia.

Step-by-step explanation:

After a thyroidectomy, it is essential for the nurse to assess for signs of hemorrhage or airway obstruction during the first four hours post-surgery. This is a critical period when complications such as bleeding and swelling can compromise the patient's airway, and due to the effects of general anesthesia, the muscles necessary for breathing and moving the tongue may not be fully functional. Additionally, the patient may experience a sore or scratchy throat from the endotracheal intubation used to maintain their airway during the procedure. Thyroid hormone replacement therapy is important post-thyroidectomy, but immediate administration post-surgery is not typically the priority; careful monitoring over time is needed to adjust levels properly, as it often takes weeks or months for thyroid hormone levels to stabilize. While a high-protein diet might help in healing, it is not an immediate nursing action in the first four hours post-operation.