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Question

Difficulty: MediumReduction of Risk Potential

A nurse is developing a plan of care for a client who is 2 hours postoperative following a total thyroidectomy. Which of the following nursing actions are appropriate to reduce the risk of postoperative complications? Select all that apply.

  1. Maintain the client in a semi-Fowler's position with pillows supporting the head and neck.Answer
  2. B
    Place the client in a supine position to stabilize the cervical spine and promote optimal cerebral perfusion.
  3. C
    Rely on a drop in systolic blood pressure as the primary indicator to notify the provider of potential hemorrhagic shock.
  4. Keep a tracheostomy tray, suction equipment, and supplemental oxygen readily available at the bedside.Answer
  5. E
    Delegate the hourly assessment of the posterior neck dressing for dependent bleeding to the unlicensed assistive personnel (UAP).
  6. Ask the client to speak briefly every 1 to 2 hours to monitor for changes in voice quality.Answer

Answer

The appropriate actions include maintaining a semi-Fowler's position with neck support, keeping emergency airway equipment at the bedside, and assessing voice quality frequently.
The correct actions actively prevent or prepare for life-threatening complications. Semi-Fowler's positioning minimizes airway edema and suture tension. Bedside emergency equipment ensures immediate readiness for airway obstruction. Periodic voice assessments effectively monitor for laryngeal nerve damage.

Step-by-Step Solution

1
Identify the surgical procedure and its specific high-risk complications.
A total thyroidectomy carries significant risks of airway obstruction, hemorrhage, hypocalcemia, and laryngeal nerve damage.
Anticipating specific surgical complications is the foundation of effective risk reduction.
2
Evaluate positioning strategies for the post-thyroidectomy client.
Semi-Fowler's position is indicated; the supine position is contraindicated.
Elevating the head reduces neck edema, and supporting the neck prevents tension on the surgical incision.
3
Determine appropriate assessment and monitoring responsibilities.
The nurse must monitor early signs of shock (tachycardia) rather than late signs (hypotension), and must independently assess the surgical site.
Early recognition prevents severe physiological decompensation, and clinical assessments cannot be delegated to assistive personnel.

Key Concept

Reduction of Risk Potential: Postoperative Complications
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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