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Soru

Zorluk: OrtaReduction of Risk Potential

While performing an afternoon assessment on a client who underwent a total thyroidectomy earlier in the day, the licensed practical nurse notes the client has become visibly restless. The client's voice is increasingly hoarse, and they mention a new sensation of tightness in the anterior neck area. Current vital signs show a heart rate of 114 beats/min and a respiratory rate of 24 breaths/min. Which action should the nurse take first?

  1. A
    Administer the prescribed as-needed opioid analgesic to relieve the surgical site discomfort.
  2. B
    Instruct the client to perform deep breathing and relaxation exercises to reduce postoperative restlessness.
  3. Alert the registered nurse immediately and verify that an emergency tracheostomy tray is at the bedside.Cevap
  4. D
    Carefully loosen the edges of the surgical dressing to alleviate the feeling of pressure on the neck.

Cevap

The nurse should immediately alert the registered nurse and ensure emergency airway equipment is present.
Following a thyroidectomy, a new sensation of neck tightness, hoarseness, restlessness, tachycardia, and tachypnea are classic early indicators of a developing hematoma or laryngeal edema. This is a life-threatening complication that can rapidly occlude the airway. The practical nurse must prioritize airway management by immediately escalating these findings to the registered nurse and ensuring emergency equipment (such as a tracheostomy tray) is readily available to mitigate the risk of respiratory arrest.

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1
Analyze the client's new symptoms: restlessness, hoarseness, neck tightness, tachycardia (114 beats/min), and tachypnea (24 breaths/min).
Recognize these findings as indicative of a developing neck hematoma or laryngeal edema.
Following a thyroidectomy, bleeding into the tissue spaces can rapidly compress the trachea, presenting initially as local pressure and subtle respiratory distress.
2
Determine the appropriate priority intervention based on the practical nursing scope of practice.
Identify that the situation represents a life-threatening airway emergency requiring immediate escalation.
Airway compromise requires advanced assessment, potential rapid response team activation, and possible emergency surgical intervention.
3
Select the action that protects the client's safety.
Notify the RN immediately and confirm the availability of a tracheostomy tray.
This action ensures the team is aware of the critical change and is prepared for immediate advanced airway management.

Anahtar Kavram

Recognizing and Escalating Early Signs of Postoperative Complications
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Konular

Reduction of Risk Potential

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