Examkin

Question

Difficulty: MediumReduction of Risk Potential

While evaluating a client who returned from the post-anesthesia care unit 4 hours ago following a subtotal thyroidectomy, a practical nurse notes that the client appears increasingly restless. The client states, "My neck feels a little tight." The current vital signs reveal a heart rate of 116 beats/minute, a blood pressure of 96/58 mm Hg, and a respiratory rate of 22 breaths/minute. Which action is the priority for the practical nurse?

  1. Notify the registered nurse immediately of the client's changing status.Answer
  2. B
    Document the findings as expected postoperative recovery progress.
  3. C
    Provide the prescribed analgesic to relieve the client's neck tightness.
  4. D
    Assign the unlicensed assistive personnel to monitor the client's oxygen saturation every 15 minutes.

Answer

The priority action is to notify the registered nurse immediately of the client's changing status.
A feeling of neck tightness, restlessness, tachycardia, and hypotension following a thyroidectomy strongly indicate a developing hematoma or hemorrhage. This complication can rapidly compress the trachea and compromise the airway. The practical nurse must promptly report these critical findings to the registered nurse or healthcare provider to ensure rapid emergency intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client exhibits restlessness, a feeling of neck tightness, tachycardia, and a lowered blood pressure 4 hours post-thyroidectomy.
Identifying the onset of new or worsening symptoms is the first step in nursing assessment.
2
Recognize the physiological risk.
These symptoms are classic early indicators of hemorrhage or a developing neck hematoma, which can cause life-threatening airway obstruction.
Connecting postoperative symptoms to potential complications allows the nurse to prioritize interventions.
3
Determine the appropriate practical nursing action.
The practical nurse must immediately communicate these critical changes to the registered nurse or provider for emergency medical intervention.
Rapid escalation is required when a client shows signs of airway compromise or shock.

Key Concept

Reduction of Risk Potential: Recognizing and escalating signs of postoperative hemorrhage and airway compromise
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic