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Difficulty: MediumPhysiological Adaptation

During a postoperative assessment of a client who had a subtotal thyroidectomy 6 hours ago, the practical nurse notes that the client's heart rate has increased from a baseline of 82 bpm to 114 bpm, and blood pressure has decreased from 124/76 mmHg to 102/58 mmHg. The client appears restless and states, "My neck dressing feels a bit tighter than before." Which of the following is the priority nursing action?

  1. Inspect the back of the client's neck for pooling blood and immediately notify the registered nurse.Answer
  2. B
    Provide the client with a dose of the PRN pain medication for their neck pain.
  3. C
    Document the vital signs as a normal physiological response to surgical stress.
  4. D
    Reassure the client that anxiety is common and guide them through deep breathing exercises.

Answer

The priority action is to check the dependent area behind the client's neck for bleeding and escalate the critical findings to the registered nurse without delay.
Following a thyroidectomy, a tightening dressing combined with restlessness, an increasing heart rate, and a decreasing blood pressure strongly suggest hemorrhage. Blood often pools dependently at the back of the neck due to gravity. The practical nurse must immediately assess this area and notify the registered nurse to prevent hypovolemic shock and acute airway obstruction.

Step-by-Step Solution

1
Analyze the client's postoperative clinical cues.
The client presents with a new onset of tachycardia, mild hypotension, restlessness, and a sensation of a tightening dressing.
Identifying these specific changes establishes a baseline for recognizing acute physiological decompensation.
2
Correlate the cues with potential surgical complications.
These findings collectively indicate a high probability of active hemorrhage and potential airway compression.
After a thyroidectomy, bleeding can pool dependently behind the neck and compress the trachea, creating a life-threatening emergency.
3
Determine the priority nursing action within the practical nurse scope.
The nurse must immediately inspect the dependent area for bleeding and report the findings to the registered nurse.
Prompt escalation ensures the client receives necessary emergency medical interventions to stabilize circulation and secure the airway.

Key Concept

Early recognition of postoperative hemorrhage and airway compromise
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Topics

Physiological Adaptation

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