A -year-old client is recovering in the surgical unit following a subtotal thyroidectomy performed earlier in the day. During afternoon rounding, the nurse observes the client swallowing repeatedly and reporting a sensation of severe tightness in the anterior neck region. The client's heart rate has trended from to beats per minute over the past hour. Which action is essential for the nurse to perform immediately to mitigate potential physiological risk?
- Inspect the anterior surgical dressing and the posterior aspect of the neck for active bleeding or pooling.Answer
- BPlace the client in a supine position with a small rolled towel under the shoulders to maintain airway alignment.
- CAssess for latent neuromuscular irritability by tapping the facial nerve just below the temple.
- DAdminister the prescribed as-needed intravenous analgesic to manage anticipated post-surgical discomfort.
Answer
Inspect the anterior surgical dressing and the posterior aspect of the neck for active bleeding or pooling.
The combination of repeated swallowing, a sensation of neck tightness, and a rising heart rate post-thyroidectomy strongly points to hemorrhage and hematoma formation. Because blood can track backward and pool dependently, the nurse must urgently inspect both the anterior dressing and the posterior neck. Recognizing this complication early is critical to reducing the risk of complete airway obstruction.
Step-by-Step Solution
Key Concept
Postoperative hemorrhage and airway compromise
Estimated Time:1m 30s