Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A practical nurse is assigned to care for a client who returned to the surgical unit 2 hours ago following a subtotal thyroidectomy. The client reports mild incisional discomfort. Which positioning intervention should the nurse implement to promote comfort and minimize tension on the surgical site?

  1. A
    Keep the client flat on their back with a rolled towel placed directly beneath the cervical spine.
  2. Adjust the bed to a semi-Fowler's angle and stabilize the head and neck using supportive pillows.Cevap
  3. C
    Turn the client into a side-lying alignment with the bed positioned completely flat.
  4. D
    Sit the client straight up at a 90-degree angle with the chin resting toward the chest.

Cevap

Adjust the bed to a semi-Fowler's angle and stabilize the head and neck using supportive pillows.
Adjusting the bed to a semi-Fowler's angle (approximately 30 to 45 degrees) utilizes gravity to decrease swelling at the surgical site. Stabilizing the head and neck with pillows prevents hyperextension or hyperflexion, keeping the neck in a neutral position. This combination ensures optimal airway patency, reduces tension on the surgical incision, and maximizes client comfort.

Adım Adım Çözüm

1
Identify the surgical procedure and its anatomical location.
The client had a subtotal thyroidectomy, which involves an incision in the anterior neck.
Understanding the surgical site is essential for determining the correct positioning to prevent complications.
2
Determine the primary physiological risks associated with the immediate postoperative period.
Risks include localized edema causing airway obstruction, and tension on the suture line causing hemorrhage.
Nursing interventions must be chosen to mitigate these specific, life-threatening complications.
3
Select the position that addresses these risks while promoting client comfort.
A semi-Fowler's position with the head and neck supported in a neutral alignment.
Elevation reduces swelling via gravity, and firm support prevents flexion or hyperextension of the neck.

Anahtar Kavram

Postoperative Positioning and Airway Protection

Daha Fazla Pratik

Review the early signs of respiratory distress and hypocalcemia following a thyroidectomy.

Alternatif Yöntem

When thinking about post-neck surgery care, remember the 'E and N' rule: Elevate (to reduce swelling) and Neutral (to prevent suture tension).
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru