Registered Nurse (RN) Endocrine Licensure Exam

After a thyroidectomy for Grave's Disease, which finding requires nursing intervention?

1. Patient complains of pain with a score of 4 on a scale of 1 to 10

2. Patient positioned in supine position

3. Patient's Foley catheter draining 50 cc of urine per hour

4. Patient splinting neck while coughing

The correct answer is: Patient positioned in supine position

Following a thyroidectomy for Graves' Disease, it is crucial for nurses to monitor the patient's positioning and ensure that it is conducive to recovery. A patient positioned in supine without appropriate support can lead to complications such as airway obstruction, especially if there is swelling or bleeding in the neck area. This position may also contribute to strain on the surgical site and increase discomfort. In contrast, the other findings noted would generally be considered within acceptable limits. A pain score of 4 indicates a moderate level of discomfort but does not necessitate immediate intervention unless it escalates or is unmanageable. A Foley catheter draining 50 cc of urine per hour suggests adequate renal function and hydration, although ongoing assessment would be necessary to monitor for any changes. Additionally, a patient splinting the neck while coughing is a protective measure that helps reduce strain and pain at the surgical site. This indicates an understanding of the need to protect the area while allowing for bodily functions such as coughing. Therefore, the nursing intervention should focus on ensuring the patient's positioning supports their safety and comfort post-surgery.