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Difficulty: MediumReduction of Risk Potential

While conducting an afternoon assessment on a client who underwent a partial thyroidectomy six hours ago, a licensed practical nurse observes the client's pulse is 114 beats per minute, respirations are 22 per minute, and blood pressure is 94/62 mm Hg. The client states, 'I feel really jittery right now.' What is the priority action for the nurse to take?

  1. Alert the registered nurse to the current clinical findings immediatelyAnswer
  2. B
    Administer a prescribed as-needed medication for anxiety
  3. C
    Record the assessment data and plan to recheck the client in two hours
  4. D
    Reposition the client to lie flat to help improve blood pressure

Answer

The correct action is to immediately alert the registered nurse to the current clinical findings.
The client is exhibiting early signs of shock or potential internal hemorrhage, characterized by tachycardia, borderline hypotension, and restlessness (described as feeling 'jittery'). In the postoperative period, the licensed practical nurse must prioritize client safety by immediately reporting these subtle but critical changes to the registered nurse so that further medical assessment and life-saving interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and verbal statements.
The pulse of 114 beats per minute and blood pressure of 94/62 mm Hg are borderline abnormal, and feeling 'jittery' is a classic sign of restlessness.
Identifying subtle deviations from normal baseline values is essential for recognizing early complications.
2
Correlate findings with postoperative risks for a thyroidectomy.
These findings collectively act as early indicators of potential internal hemorrhage or hypovolemic shock, which are critical complications.
Understanding the clinical implications of assessment data guides the urgency of necessary nursing interventions.
3
Determine the priority action within the practical nurse scope of practice.
The absolute priority is to escalate these critical findings to the registered nurse for further assessment and collaborative intervention.
Practical nurses must promptly report rapid changes indicating a severe risk to client safety rather than attempting to manage a potential crisis independently.

Key Concept

Early recognition of shock and appropriate escalation of critical findings
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Topics

Reduction of Risk Potential

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