The nurse is assigned to care for a client who had a thyroidectomy 24 hours ago. On initial assessment, which finding requires the most immediate action by the nurse?

Question

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Stridor is a high-pitched, vibratory, harsh sound during inspiration or expiration that indicates partial airway obstruction. When stridor occurs after a thyroidectomy, a delicate surgery involving a highly vascularized area, the most immediate concern is airway compromise secondary to hemorrhage or laryngeal edema. This is a life-threatening complication requiring immediate intervention. The nurse should ensure that suctioning devices, oxygen, and a tracheostomy tray are readily available in the recovery room as immediate tracheostomy may be necessary. Respiratory stridor, also observed in epiglottitis, is very different from the minor laryngeal edema that commonly occurs after intubation and results in transient hoarseness in the postoperative period. Persistent hoarseness and the inability to raise one's voice more than 24 hours postoperatively may indicate damage to the laryngeal nerve, a frequent complication of thyroid surgery. (Option A) This calcium level is normal (8.6-10.2 mg/dL [2.15-2.55 mmol/L]). However, hypocalcemia is a potential complication of a thyroidectomy as the parathyroid glands that regulate calcium levels in the blood are often inadvertently removed or damaged during surgery. The nurse should ensure that calcium gluconate is available. (Options B and D) Although the pain and tachycardia warrant action by the nurse, these are not as high a priority as the life-threatening complication of airway obstruction. Educational objective: Stridor indicates airway obstruction, and abrupt onset is a medical emergency. Stridor after thyroidectomy requires immediate action by the nurse to maintain airway patency. Suctioning devices, oxygen, and a tracheostomy tray should be available for rapid surgical intervention.

The Nurse Is Assigned to Care for a Client Who