While checking on a client who underwent a subtotal thyroidectomy earlier in the shift, the practical nurse observes that the client is unusually restless. The client points to the surgical area and whispers, "It feels really tight in my neck." Which action should the nurse take first?
- Evaluate the client's respiratory rate, effort, and oxygen saturation.Answer
- BReassure the client that a sore and tight throat is expected from the breathing tube.
- CAdminister the prescribed as-needed analgesic to relieve surgical discomfort.
- DLower the head of the bed completely flat to decrease tension on the neck.
Answer
The nurse must first evaluate the client's respiratory rate, effort, and oxygen saturation to assess for an airway obstruction.
Following a thyroidectomy, the client is at an elevated risk for airway compromise due to localized swelling, edema, or hemorrhage (hematoma formation). Restlessness is a classic early sign of hypoxia, and the sensation of neck tightness strongly suggests physical airway compression. Applying the ABC (Airway, Breathing, Circulation) framework dictates that the nurse must assess the client's respiratory status and airway patency immediately before initiating any other intervention.
Step-by-Step Solution
Key Concept
Postoperative Airway Prioritization