A practical nurse (PN) is assigned to a 68-year-old client who is 4 hours postoperative following a total thyroidectomy. The client's current vital signs are: blood pressure 94/58 mm Hg (baseline 132/82 mm Hg), heart rate 116 beats/minute, and respiratory rate 24 breaths/minute. The client is also experiencing new-onset restlessness and confusion. Which of the following actions should the PN take? (Select all that apply.)
- Notify the registered nurse (RN) and healthcare provider immediately about the client's status.Cevap
- Inspect the surgical dressing and the area behind the client's neck for pooling blood.Cevap
- Verify that suction equipment and an emergency tracheostomy tray are readily accessible.Cevap
- DReassure the family that sudden confusion is an expected reaction to anesthesia in older adults.
- EPrioritize the administration of a prescribed oral analgesic to manage the client's incisional pain.
- FDocument the vital signs and plan to recheck them during the next scheduled hourly round.
Cevap
The correct actions are to notify the registered nurse (RN) immediately, inspect the dressing and the back of the neck for bleeding, and verify that emergency airway equipment is accessible.
The client is demonstrating signs of acute physiological decompensation, specifically early hypovolemic shock (tachycardia, hypotension) and hypoxia (restlessness, confusion), likely due to postoperative hemorrhage or airway compromise. Appropriate actions include immediately notifying the RN, assessing the surgical site and the dependent area behind the neck for pooling blood, and ensuring emergency airway equipment is available due to the high risk of airway obstruction following a thyroidectomy.
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Anahtar Kavram
Recognizing and managing acute postoperative complications (hemorrhage, airway obstruction) and prioritizing airway, breathing, and circulation (ABCs).