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Difficulty: HardPhysiological Adaptation

A 71-year-old client is 14 hours post-subtotal thyroidectomy. While rounding, the nurse notices the client appears highly anxious, is repeatedly clearing their throat, and complains of a feeling of pressure in the neck. The anterior surgical dressing is clean, dry, and intact. Vital signs reveal a heart rate of 106 beats per minute and blood pressure of 108/68 mm Hg. Which action should the nurse take first?

  1. Examine the posterior neck area for pooling blood and immediately alert the registered nurse.Answer
  2. B
    Administer the prescribed as-needed throat lozenges and oral analgesic to relieve the surgical discomfort.
  3. C
    Record the vital signs and client reports in the chart as expected postoperative findings.
  4. D
    Dim the room lights and reassure the client that temporary restlessness is a normal reaction to anesthesia in older adults.

Answer

Examine the posterior neck area for pooling blood and immediately alert the registered nurse.
The correct answer directly addresses a life-threatening complication. After neck surgery, frequent throat clearing, feelings of fullness, anxiety, and an increasing heart rate are classic indicators of a hematoma. Because the client is typically in a semi-Fowler or supine position, blood drains to the back of the neck. The nurse must quickly check this dependent area and immediately escalate the situation to the registered nurse for potential rapid airway intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has anxiety, frequent throat clearing, neck pressure, and mild tachycardia 14 hours after a thyroidectomy.
Identifying these specific symptoms is crucial for recognizing postoperative complications.
2
Relate the symptoms to potential complications of the specific surgery.
These symptoms strongly suggest the formation of a hematoma or active hemorrhage compressing the airway.
The neck is a confined space; bleeding quickly leads to life-threatening tracheal deviation and airway obstruction.
3
Evaluate the clinical evidence provided in the stem.
The anterior dressing is dry, but blood follows gravity. The client is likely bleeding internally or dependently.
Understanding anatomical positioning helps the nurse locate hidden bleeding that isn't immediately visible on the surgical incision.
4
Determine the highest priority nursing intervention.
The nurse must assess the dependent area (back of the neck) for blood and notify the RN immediately.
Airway protection is the absolute priority; the RN and provider must be alerted immediately to intervene.

Key Concept

Post-Thyroidectomy Hemorrhage and Airway Compromise
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Topics

Physiological Adaptation

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