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Question

Difficulty: MediumReduction of Risk Potential

An adult client is recovering on the surgical unit 12 hours after a total thyroidectomy. The practical nurse is planning care to prevent and identify potential postoperative emergencies. Which of the following actions should the nurse include? Select all that apply.

  1. Verify that an emergency tracheostomy kit and functioning suction equipment are present at the bedside.Answer
  2. Monitor the client for reports of numbness or tingling around the mouth and fingertips.Answer
  3. Check the surgical dressing and the back of the client's neck for unexpected pooling of blood.Answer
  4. D
    Maintain the client in a flat, supine position to prevent flexion of the neck.
  5. E
    Administer prescribed intravenous push calcium gluconate immediately if tetany develops.
  6. F
    Document a new resting heart rate of 105 beats per minute without immediately notifying the registered nurse.

Answer

The appropriate actions are verifying emergency airway equipment is at the bedside, monitoring for perioral and extremity numbness, and checking the back of the neck for blood pooling.
Appropriate risk reduction following a thyroidectomy includes preparing for potential airway emergencies, assessing for hidden bleeding behind the neck, and closely monitoring for signs of parathyroid gland damage (hypocalcemia), such as perioral tingling.

Step-by-Step Solution

1
Identify the client's specific surgical risks based on the procedure.
Primary risks include airway obstruction, hidden hemorrhage, and hypocalcemia.
A thyroidectomy involves the anterior neck, placing the airway, major blood vessels, and parathyroid glands at risk.
2
Evaluate the proposed monitoring actions against these specific risks.
Actions targeting airway preparation, detecting subtle hemorrhage, and recognizing calcium deficit signs are appropriate.
These actions actively reduce the potential for severe complications and align with established protocols.
3
Identify actions that are outside the scope of practice or clinically contraindicated.
Supine positioning, administering IV push medications, and delaying reports of tachycardia are unsafe.
These actions violate the practical nurse's scope of practice, post-procedure positioning standards, and early escalation requirements.

Key Concept

Reduction of postoperative risks following a thyroidectomy requires anticipating airway compromise, assessing for hidden hemorrhage, monitoring for hypocalcemia, and operating strictly within the practical nursing scope of practice.
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Topics

Reduction of Risk Potential

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