A licensed practical nurse (LPN) is assisting with the care of a client who is 6 hours postoperative following a subtotal thyroidectomy. Which of the following nursing actions are appropriate to reduce the client's risk for complications? Select all that apply.
- Verify that a tracheostomy tray and working suction equipment are immediately available at the bedside.Cevap
- Promptly notify the registered nurse if the client's serum calcium level is reported as 7.4 mg/dL (1.85 mmol/L).Cevap
- CDocument a heart rate of 114 beats per minute and a blood pressure of 92/58 mm Hg as expected physiological responses to surgical stress.
- DAssign unlicensed assistive personnel (UAP) to monitor the client for frequent swallowing during the initial intake of clear liquids.
- Maintain the client in a semi-Fowler's position with pillows supporting the head and neck to prevent hyperextension.Cevap
- FAdminister a prescribed as-needed (PRN) opioid analgesic as the primary intervention when the client exhibits a harsh, high-pitched respiratory sound.
Cevap
The correct actions include verifying bedside availability of a tracheostomy tray and suction, notifying the registered nurse of the critically low serum calcium level, and maintaining the client in a semi-Fowler's position with neck support.
The correct actions prioritize the most life-threatening risks associated with a thyroidectomy. Maintaining a semi-Fowler's position prevents stress on the incision, minimizing bleeding risk. Having emergency airway equipment ready ensures a rapid response if tracheal compression occurs from a hematoma. Reporting a calcium level of 7.4 mg/dL is critical, as it is abnormally low and suggests the parathyroid glands were damaged or removed, which can lead to life-threatening tetany.
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Anahtar Kavram
Post-thyroidectomy risk reduction involves prioritizing airway patency, monitoring for signs of hemorrhage (frequent swallowing, vital sign changes), and identifying hypocalcemia.