A practical nurse (PN) is evaluating a client who is 6 hours postoperative following a total thyroidectomy. The client's current vital signs are: heart rate 114 beats/min, blood pressure 104/58 mm Hg, respiratory rate 18 breaths/min, and temperature 99.2°F (37.3°C). The morning laboratory results reveal a serum calcium level of 7.4 mg/dL (1.85 mmol/L). Which of the following actions should the PN take? (Select all that apply.)
- Notify the registered nurse (RN) immediately regarding the client's vital signs and laboratory results.Cevap
- Assess the client for the presence of Chvostek's sign or perioral numbness.Cevap
- CDocument the vital signs as stable postoperative findings and reassess in 4 hours.
- DAdminister a prescribed intravenous push (IVP) dose of calcium gluconate.
- Ensure that emergency suction equipment and a tracheostomy tray are at the bedside.Cevap
- FWithhold reporting the serum calcium level until the routine end-of-shift handoff.
Cevap
The correct actions include notifying the RN immediately, assessing the client for signs of hypocalcemia (such as Chvostek's sign or numbness), and ensuring emergency airway equipment is kept at the bedside.
Following a total thyroidectomy, clients face immediate risks of hemorrhage, airway compromise, and hypocalcemia. The client's tachycardia and borderline hypotension may indicate early shock. The calcium level of 7.4 mg/dL is critically low. To reduce risk potential safely, the PN must escalate these findings to the RN immediately, assess for symptoms of tetany (such as Chvostek's sign), and ensure emergency airway equipment is physically present at the bedside.
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Following a thyroidectomy, reduction of risk potential requires vigilant monitoring for hypovolemic shock, airway compromise, and hypocalcemia, combined with immediate escalation of critical findings and adherence to the PN scope of practice.