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Difficulty: HardReduction of Risk Potential

A nurse is caring for a client who is four hours post-operative following a total thyroidectomy. The client suddenly becomes highly agitated and reports a sensation of intense pressure and fullness in the neck. Upon inspection, the surgical dressing is dry and intact, but the nurse auscultates high-pitched, harsh respiratory sounds during inspiration. The client's voice has become noticeably muffled. Which action should the nurse take immediately?

  1. Elevate the head of the bed to a semi-Fowler's position and activate the rapid response team.Answer
  2. B
    Lower the head of the bed to a supine position and hyperextend the neck to maximize airway patency.
  3. C
    Assess for a positive Trousseau's sign and prepare to administer intravenous calcium gluconate.
  4. D
    Apply a pulse oximeter and obtain an arterial blood gas sample to evaluate the degree of respiratory acidosis.

Answer

The nurse should immediately elevate the head of the bed to a semi-Fowler's position and activate the rapid response team.
The client's presentation of agitation, neck fullness, a muffled voice, and inspiratory stridor strongly indicates a rapidly expanding neck hematoma causing tracheal compression. This is a life-threatening airway emergency. The immediate priority is to elevate the head of the bed to a semi-Fowler's position to promote venous return, decrease local tissue edema, and facilitate breathing, while simultaneously activating the rapid response team for potential emergency intubation or bedside surgical decompression.

Step-by-Step Solution

1
Analyze the client's clinical presentation, noting the agitation, neck fullness, muffled voice, and inspiratory stridor.
These findings are classic indicators of a rapidly expanding neck hematoma causing tracheal compression.
Early recognition of post-operative complications is essential to prevent physiological collapse.
2
Prioritize interventions using the Airway, Breathing, Circulation (ABC) framework.
Airway compromise is the most imminent threat to the client's life and requires the highest priority action.
Metabolic issues (like hypocalcemia) or diagnostic testing must not delay life-saving airway management.
3
Implement the safest and most effective initial mechanical intervention while securing emergency assistance.
Elevating the head of the bed reduces venous pressure and tissue edema, temporarily easing breathing while the rapid response team prepares for emergency airway management.
Proper positioning mitigates further risk without placing tension on the surgical incision.

Key Concept

Early recognition and management of an expanding neck hematoma and airway compromise following a thyroidectomy.
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Reduction of Risk Potential

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