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Soru

Zorluk: OrtaReduction of Risk Potential

While conducting evening rounds on a medical-surgical unit, a practical nurse evaluates a client who is 12 hours post-thyroidectomy. The client states, 'My lips and fingers feel like they are vibrating.' The nurse observes a respiratory rate of 22 breaths/min, a heart rate of 108 beats/min, and a blood pressure of 102/64 mm Hg. The most recent serum calcium level is reported as 7.2 mg/dL (1.80 mmol/L). Which action should the practical nurse take immediately?

  1. Report the clinical symptoms, vital signs, and laboratory results to the supervising registered nurse.Cevap
  2. B
    Document the findings in the electronic health record and recheck the calcium level during the morning draw.
  3. C
    Administer a prescribed intravenous push dose of calcium gluconate to correct the electrolyte deficit.
  4. D
    Offer a prescribed oral analgesic and continue to monitor the mild tachycardia and hypotension.

Cevap

Report the clinical symptoms, vital signs, and laboratory results to the supervising registered nurse.
The client is exhibiting characteristic signs of acute hypocalcemia (circumoral and extremity paresthesia) following a thyroidectomy. This condition can rapidly progress to life-threatening laryngospasm, seizures, or cardiac arrhythmias. The practical nurse must immediately escalate these critical assessment findings, borderline vital signs, and abnormal laboratory values to the registered nurse for prompt collaborative intervention.

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1
Analyze the client's reported symptoms and laboratory data.
The client reports tingling in the lips and fingers (paresthesia), and has a serum calcium level of 7.2 mg/dL, indicating acute and severe hypocalcemia.
Thyroidectomy carries a high risk of inadvertent parathyroid gland removal or damage, which abruptly disrupts calcium regulation.
2
Evaluate the current vital signs for additional signs of physiological instability.
The heart rate of 108 beats/min and blood pressure of 102/64 mm Hg are borderline vital signs indicating potential compensatory mechanisms.
Severe hypocalcemia severely impairs cardiac contractility, and postoperative bleeding into the neck is a concurrent risk requiring vigilant monitoring.
3
Determine the appropriate, safe nursing intervention within the practical nurse scope of practice.
The immediate and safest action is to escalate the findings to the supervising registered nurse.
The practical nurse must recognize impending life-threatening complications (such as tetany or laryngospasm) and coordinate care, as correcting severe hypocalcemia requires RN or provider-level interventions.

Anahtar Kavram

Recognizing and escalating signs of acute postoperative hypocalcemia and borderline vital signs.
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Konular

Reduction of Risk Potential

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