Examkin

Question

Difficulty: HardPhysiological Adaptation

A practical nurse (PN) is caring for a client who is 6 hours postoperative following a total thyroidectomy. Upon entering the room, the PN notes that the client is restless, swallowing frequently, and has a heart rate of 114 beats/min. The client's blood pressure is 98/64 mm Hg. Which of the following immediate actions should the PN take? (Select all that apply.)

  1. Elevate the head of the client's bed to a semi-Fowler's positionAnswer
  2. Notify the supervising registered nurse (RN) immediatelyAnswer
  3. C
    Administer the prescribed as-needed (PRN) analgesic for incisional discomfort
  4. D
    Document the findings as expected postoperative data and reassess in one hour
  5. Verify that functional suction equipment and a tracheostomy tray are at the bedsideAnswer
  6. F
    Provide small sips of clear water to soothe the client's throat irritation

Answer

The PN must elevate the head of the bed, notify the RN immediately, and verify that suction and a tracheostomy tray are at the bedside.
The client is demonstrating classic signs of post-thyroidectomy hemorrhage (frequent swallowing, restlessness, tachycardia, and borderline hypotension). This complication can rapidly lead to airway compression from a growing hematoma. The correct actions prioritize airway protection and immediate escalation. Elevating the head of the bed decreases venous pressure and tissue edema in the neck. Verifying the presence of suction and a tracheostomy tray ensures preparedness for a sudden airway obstruction. Notifying the RN is critical because these findings indicate an unstable client requiring rapid advanced interventions.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client has restlessness, frequent swallowing, tachycardia (114 beats/min), and borderline hypotension (98/64 mm Hg).
Identifying abnormal findings is the first step in clinical judgment to determine if the client is stable or deteriorating.
2
Correlate the cues with potential postoperative complications of a thyroidectomy.
Frequent swallowing indicates blood accumulating in the throat. Restlessness, tachycardia, and low blood pressure indicate early hemorrhagic shock and impending airway compression.
Connecting symptoms to the specific surgical risk (neck hematoma) establishes the severity of the situation.
3
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
The PN must secure the airway by elevating the head of the bed, confirm emergency equipment (tracheostomy tray/suction) is present, and immediately escalate to the RN.
Airway compromise and shock are life-threatening emergencies that require immediate action and RN/provider intervention.
4
Reject interventions that delay care or cause harm.
Do not administer pain medication, do not wait an hour to reassess, and do not offer fluids.
These actions mask symptoms, dismiss early shock indicators, and increase the risk of aspiration.

Key Concept

Postoperative complications of thyroidectomy: recognizing and managing hemorrhage and airway compromise.
Estimated Time:1m 30s
Rate this question

Topics

Physiological Adaptation

More questions from this topic