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Question

Difficulty: MediumReduction of Risk Potential

A medical-surgical nurse is developing a plan of care for a client who is 2 hours postoperative following a subtotal thyroidectomy. Which of the following interventions should the nurse include to reduce the risk of physiological complications? (Select all that apply.)

  1. Maintain the client in a semi-Fowler's position with the head and neck supported in neutral alignmentAnswer
  2. Assess the anterior surgical dressing and palpate the posterior neck for occult bleedingAnswer
  3. Ensure intravenous calcium gluconate is immediately available on the surgical unitAnswer
  4. D
    Place the client flat in a supine position to maximize oxygenation and airway patency
  5. E
    Monitor for bradycardia and a widened pulse pressure as the earliest physiological indicators of surgical hemorrhage
  6. F
    Delegate the initial post-operative assessment of the client's swallowing ability to the unlicensed assistive personnel

Answer

The correct actions are maintaining a semi-Fowler's position with neutral neck alignment, assessing the anterior dressing and posterior neck for bleeding, and ensuring intravenous calcium gluconate is available.
Following a thyroidectomy, clients are at high risk for airway compromise, hemorrhage, and hypocalcemia. Maintaining a semi-Fowler's position minimizes neck edema, assessing the posterior neck detects occult bleeding, and having calcium gluconate available prepares the team for potential parathyroid gland damage.

Step-by-Step Solution

1
Identify the surgical procedure and the timeframe.
The client is 2 hours postoperative following a subtotal thyroidectomy.
Understanding the procedure and timing helps anticipate immediate postoperative risks.
2
Determine the major risks associated with this surgery.
Primary risks include airway obstruction from edema, occult hemorrhage, and hypocalcemia due to accidental parathyroid gland damage.
Risk reduction potential relies on recognizing these specific threats early.
3
Evaluate each intervention against the identified risks.
Semi-Fowler's position reduces edema; checking the posterior neck detects hidden bleeding; and having calcium gluconate ready addresses potential hypocalcemia.
These specific actions directly mitigate the highest-priority physiological risks.

Key Concept

Reduction of Risk Potential: Postoperative Care and Complication Prevention
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Topics

Reduction of Risk Potential

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