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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is assigned to a 68-year-old client who is 4 hours postoperative following a total thyroidectomy. The client's current vital signs are: blood pressure 94/58 mm Hg (baseline 132/82 mm Hg), heart rate 116 beats/minute, and respiratory rate 24 breaths/minute. The client is also experiencing new-onset restlessness and confusion. Which of the following actions should the PN take? (Select all that apply.)

  1. Notify the registered nurse (RN) and healthcare provider immediately about the client's status.Answer
  2. Inspect the surgical dressing and the area behind the client's neck for pooling blood.Answer
  3. Verify that suction equipment and an emergency tracheostomy tray are readily accessible.Answer
  4. D
    Reassure the family that sudden confusion is an expected reaction to anesthesia in older adults.
  5. E
    Prioritize the administration of a prescribed oral analgesic to manage the client's incisional pain.
  6. F
    Document the vital signs and plan to recheck them during the next scheduled hourly round.

Answer

The correct actions are to notify the registered nurse (RN) immediately, inspect the dressing and the back of the neck for bleeding, and verify that emergency airway equipment is accessible.
The client is demonstrating signs of acute physiological decompensation, specifically early hypovolemic shock (tachycardia, hypotension) and hypoxia (restlessness, confusion), likely due to postoperative hemorrhage or airway compromise. Appropriate actions include immediately notifying the RN, assessing the surgical site and the dependent area behind the neck for pooling blood, and ensuring emergency airway equipment is available due to the high risk of airway obstruction following a thyroidectomy.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has tachycardia, hypotension, tachypnea, and new-onset confusion compared to their baseline.
These are hallmark signs of impaired tissue perfusion, hypoxia, and potential hypovolemic shock, requiring immediate attention.
2
Identify the specific surgical risks.
A total thyroidectomy carries high risks for hemorrhage and airway obstruction due to edema or bleeding in the neck.
Understanding procedure-specific complications guides targeted data collection and emergency preparation.
3
Determine the priority nursing actions within the PN scope of practice.
The PN must immediately escalate the findings to the RN, physically inspect for hemorrhage (including dependent areas), and ensure airway rescue equipment is present.
Recognizing acute instability requires rapid collaboration and safeguarding of the client's airway and circulation before the condition worsens.

Key Concept

Recognizing and managing acute postoperative complications (hemorrhage, airway obstruction) and prioritizing airway, breathing, and circulation (ABCs).
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Physiological Adaptation

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