A client is recovering on a surgical unit 4 hours after undergoing a subtotal thyroidectomy. A recent serum calcium level drawn 30 minutes ago was 7.8 mg/dL (normal: 9.0-10.5 mg/dL). The client reports a tightening sensation around the neck. The nurse observes the client swallowing repeatedly and notes that the pulse has increased to 110 bpm with a blood pressure of 104/66 mm Hg. The anterior surgical dressing is clean and dry. Which of the following is the priority nursing action?
- AAssess for a positive Chvostek sign to determine if the tightening sensation is related to the abnormal laboratory result.
- BRecord the clinical observations in the electronic health record and wait for the provider to call regarding the hypocalcemia.
- Alert the supervising registered nurse right away to report findings suggestive of an expanding hematoma and airway compromise.Answer
- DProvide a prescribed PRN throat lozenge and reassess the client's vital signs in one hour.
Answer
The priority action is to immediately alert the supervising registered nurse about the signs of an expanding hematoma and potential airway compromise.
The client's presentation of frequent swallowing, a tightening sensation in the neck, tachycardia, and a decrease in blood pressure are classic signs of an expanding hematoma following a thyroidectomy. Although the anterior dressing is dry, blood can pool posteriorly or internally, compressing the trachea. This is a life-threatening airway emergency requiring immediate escalation to the registered nurse or provider.
Step-by-Step Solution
Key Concept
Reduction of Risk Potential: Recognizing and Escalating Airway Compromise
Alternative Method
Use the ABCs (Airway, Breathing, Circulation) framework to evaluate all presenting symptoms. Any finding that threatens the airway, such as a tightening neck and frequent swallowing post-neck surgery, supersedes all other concerns including abnormal lab values.
Estimated Time:1m 30s