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Difficulty: MediumEstablishing Priorities

During hourly rounds on an adult surgical acute care unit, the nurse evaluates the status of several assigned clients. Which of the following client findings require immediate intervention? Select all that apply.

  1. A client 12 hours post-thyroidectomy who reports a tingling sensation around the mouth and fingersAnswer
  2. A client 4 hours post-splenectomy who exhibits a narrowing pulse pressure, a resting heart rate of 118 bpm, and mild restlessnessAnswer
  3. A client 48 hours post-femoral popliteal bypass graft whose affected extremity is pale and cool to the touch with an absent pedal pulseAnswer
  4. D
    A client receiving intravenous morphine via patient-controlled analgesia (PCA) whose arterial blood gas results demonstrate a pH of 7.38 and a PaCO2 of 42 mm Hg
  5. E
    A client 24 hours post-appendectomy who has a low-grade temperature of 100.2°F (37.9°C) and localized incisional pain

Answer

The correct clients are the one post-thyroidectomy reporting tingling, the one post-splenectomy with tachycardia and narrowing pulse pressure, and the one post-bypass graft with an absent pedal pulse.
The correct options represent acute, unexpected complications that pose an immediate threat to life or limb. Tingling around the mouth is an early sign of hypocalcemia which can quickly lead to laryngospasm and airway compromise. A narrowing pulse pressure with unexplained tachycardia indicates early hemorrhagic shock, a severe circulatory issue. An absent pedal pulse following a revascularization procedure indicates acute graft occlusion, which is a limb-threatening surgical emergency. All three require immediate nursing and medical intervention.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings represent an expected postoperative response or an unexpected complication.
The client with PCA has normal ABGs, and the client post-appendectomy has expected mild inflammation. The other three clients have unexpected, acute findings.
Differentiating between expected and unexpected findings is the first step in clinical triage.
2
Evaluate the unexpected findings using the Airway-Breathing-Circulation (ABC) framework and the threat to life or limb.
Hypocalcemia (tingling) threatens the airway (laryngospasm). Hemorrhagic shock (tachycardia, narrowing pulse pressure) threatens circulation. Graft occlusion (absent pulse) threatens a limb.
Clients with ABC compromises or limb-threatening emergencies take the highest priority and require immediate, concurrent interventions.

Key Concept

Prioritization of Acute Surgical Complications
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Establishing Priorities

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