While conducting a morning assessment on a surgical unit, a licensed practical nurse evaluates a client who is post-subtotal thyroidectomy. The electronic health record displays a newly resulted serum calcium level of . At the bedside, the client describes a "pins and needles" sensation around their lips and fingers. Assessment reveals a heart rate of , a blood pressure of , and mild facial muscle twitching. What is the priority action for the nurse to take?
- AProvide the client with a prescribed as-needed oral calcium supplement and record the neurological changes.
- Report the assessment data to the supervising registered nurse and verify that emergency airway equipment is present.Answer
- CAttribute the tachycardia and sensory changes to surgical anxiety and encourage guided relaxation breathing.
- DDirect the assistive personnel to stay at the bedside and initiate continuous cardiovascular monitoring.
Answer
The priority action is to report the critical findings to the supervising registered nurse and ensure emergency airway equipment is immediately accessible.
A subtotal thyroidectomy carries a high risk of accidental injury to the parathyroid glands, leading to acute hypocalcemia. A serum calcium level of , combined with perioral tingling and facial twitching (Chvostek's sign), indicates impending tetany and possible laryngospasm. The practical nurse must immediately report these critical findings to the registered nurse for intravenous calcium administration and verify that emergency airway equipment is available to prevent respiratory arrest.
Step-by-Step Solution
Key Concept
Post-thyroidectomy hypocalcemia and airway compromise