A patient has just arrived on the unit after a thyroidectomy. Which action would the nurse take first?

Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.

Choice A reason: Checking the blood pressure and pulse is important as part of the routine monitoring of vital signs to assess the patient's hemodynamic status. However, it is not the first action to take following a thyroidectomy. Ensuring that the patient's airway is clear and that there is no respiratory distress is paramount, as any compromise in the airway can lead to life-threatening situations. Blood pressure and pulse can be checked after confirming the patient is breathing properly.
Choice B reason: Observing the dressing for bleeding is also important because post-operative bleeding can be a serious concern. However, this action should follow the assessment of the patient's airway. If the patient is experiencing respiratory distress, addressing the airway takes precedence. Once it is confirmed that the airway is clear, then the nurse can check for bleeding and ensure the dressing is intact.
Choice C reason: Supporting the patient's head with pillows is beneficial for comfort and proper positioning, especially to avoid strain on the surgical site. However, positioning should not be the first priority. Ensuring that the patient's airway is clear and that there is no respiratory compromise is the most urgent concern. Proper positioning can be done after confirming that the patient is breathing adequately.
Choice D reason: Assessing the patient's respiratory effort is the first and most critical action. Following a thyroidectomy, there is a risk of respiratory complications due to potential swelling, bleeding, or damage to the trachea and surrounding structures. Immediate assessment of respiratory effort ensures that the airway is patent and the patient is not in respiratory distress. This step is crucial to prevent hypoxia and other serious complications.