A nurse is caring for a client who is hours post-total thyroidectomy. The client becomes increasingly restless and reports a "tight" sensation around the anterior neck. The nurse observes the client swallowing frequently and hears a harsh, high-pitched inspiratory sound. A recent arterial blood gas (ABG) analysis reveals a pH of , of , of , and of . Which priority action should the nurse take to reduce the client's risk of an adverse outcome?
- Elevate the head of the bed and immediately ensure the availability of an emergency tracheostomy tray.Answer
- BPlace the client in a supine position with the neck hyperextended to facilitate maximum airway opening.
- CPrepare to administer intravenous calcium gluconate to correct suspected hypocalcemia-induced respiratory alkalosis.
- DAuscultate the anterior and posterior lung fields sequentially to rule out postoperative atelectasis.
Answer
The nurse should elevate the head of the bed to decrease tissue edema and immediately prepare an emergency tracheostomy tray to manage the impending mechanical airway obstruction.
The client is displaying classic signs of a rapidly expanding cervical hematoma (frequent swallowing, feeling of tightness, stridor). The ABG confirms respiratory acidosis due to mechanical airway obstruction. The immediate priority is to reduce venous pressure by elevating the head of the bed and to prepare for an emergency surgical airway.
Step-by-Step Solution
Key Concept
Recognizing and mitigating acute airway obstruction secondary to cervical hematoma post-thyroidectomy.
Estimated Time:1m 30s