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Difficulty: MediumPhysiological Adaptation

A client is recovering from a subtotal thyroidectomy performed earlier in the day. During routine data collection, the practical nurse notes the client's heart rate is 108 beats/min and blood pressure is 102/64 mm Hg. The client states, "My neck feels very tight, and it is getting a little hard to swallow." Which action should the practical nurse take immediately?

  1. A
    Offer ice chips to soothe the throat and decrease the difficulty with swallowing.
  2. B
    Lower the head of the bed to a flat position to manage the decrease in blood pressure.
  3. Inspect the surgical dressing and the back of the client's neck for swelling or excessive bleeding.Answer
  4. D
    Document the findings since mild tachycardia and throat tightness are expected postoperatively.

Answer

The practical nurse should immediately inspect the surgical dressing and the back of the client's neck for swelling or excessive bleeding.
After a thyroidectomy, a feeling of neck tightness, difficulty swallowing, tachycardia, and a dropping blood pressure are classic signs of a surgical site hemorrhage and expanding hematoma. This life-threatening emergency can quickly compress the trachea and block the airway. The practical nurse must immediately inspect the dressing and the back of the neck (where blood can pool dependently) to gather data before promptly notifying the registered nurse or rapid response team.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
The client has tachycardia (108 beats/min), borderline hypotension (102/64 mm Hg), neck tightness, and difficulty swallowing.
Identifying abnormal data is the critical first step in recognizing a sudden clinical change.
2
Correlate the findings with potential postoperative complications of a thyroidectomy.
These findings point to an expanding hematoma, which can cause both hypovolemic shock (tachycardia, low blood pressure) and airway compression (neck tightness, difficulty swallowing).
Connecting signs and symptoms to underlying pathophysiological complications determines the severity of the situation.
3
Determine the priority nursing action based on the Airway, Breathing, and Circulation (ABC) framework.
The immediate priority is to visually assess the surgical site for bleeding and swelling before quickly escalating to the RN or provider.
Focused data collection must occur to confirm the complication and guide life-saving emergency interventions.

Key Concept

Recognition of postoperative hemorrhage and airway compromise
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Topics

Physiological Adaptation

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