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Difficulty: MediumEstablishing Priorities

A nurse is assessing a client who is 12 hours post-operative following a subtotal thyroidectomy. Which of the following assessment findings require immediate intervention or notification of the healthcare provider? (Select all that apply)

  1. The client reports a feeling of tightness and pressure in the neck area.Answer
  2. B
    The surgical drain has collected 15 mL of serosanguineous fluid over the past 4 hours.
  3. The client develops a harsh, high-pitched respiratory sound during inspiration.Answer
  4. D
    The client has a documented axillary temperature of 37.6°C (99.7°F).
  5. The client complains of a tingling sensation around the mouth and in the fingertips.Answer
  6. F
    The client reports a pain level of 4 on a 0 to 10 scale when swallowing liquids.

Answer

The findings that require immediate intervention are the feeling of neck tightness and pressure, the high-pitched respiratory sound on inspiration, and the tingling sensation around the mouth and fingertips.
Following a thyroidectomy, the most critical risks to the client are airway compromise (due to neck swelling, hematoma, or laryngeal nerve damage) and hypocalcemia (due to inadvertent removal of the parathyroid glands). A feeling of neck tightness or pressure may indicate a rapidly expanding hematoma that can compress the trachea. A high-pitched respiratory sound (stridor) indicates acute upper airway obstruction. Tingling around the mouth and fingertips is an early sign of hypocalcemia, which can rapidly progress to life-threatening tetany and laryngospasm. All three of these findings represent immediate threats to the client's airway or systemic stability and must be addressed first.

Step-by-Step Solution

1
Analyze the client's clinical context.
The client is 12 hours post-operative from a thyroidectomy.
Understanding the specific surgical procedure highlights the highest risk complications: airway compromise (from edema or hematoma) and hypocalcemia (from parathyroid gland injury).
2
Evaluate each assessment finding against the ABCs (Airway, Breathing, Circulation) and expected post-operative progression.
Neck pressure, high-pitched respiratory sounds, and tingling are abnormal and potentially life-threatening. The drainage amount, mild temperature elevation, and swallowing pain are expected post-operative findings.
Prioritization requires distinguishing between normal physiological responses to surgery and acute, deteriorating complications that threaten life.
3
Select all findings that represent acute instability.
The correct selections are the expanding neck pressure (hematoma risk), inspiratory stridor (airway obstruction), and circumoral/extremity tingling (hypocalcemia risk).
These findings directly threaten the airway or indicate an impending severe electrolyte crisis (tetany).

Key Concept

Prioritization of critical post-operative complications following thyroidectomy, specifically airway patency and calcium imbalance.
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Establishing Priorities

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