The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first?

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Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy because the parathyroids that regulate calcium levels in the blood are accidentally removed during this surgical procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (overactive neurological responses such as tingling in the hands, feet, and around the mouth; spasms or cramps that can occur even in the larynx; positive Trousseau or Chvostek sign). A serum calcium level should be drawn, and the nurse should ensure that calcium gluconate is readily available in case this complication occurs. (Option A) Monitoring for bleeding is an important assessment. However, when bleeding occurs post thyroidectomy, blood typically trickles and pools behind the client's neck. This client's symptoms are more consistent with hypocalcemia. (Option B) It is important to document findings in the electronic medical record, but the nurse should do this after taking action to help the client. (Option C) If laryngeal spasm occurs as a result of hypocalcemia, hypoxia may be evident in arterial blood gases. However, the client will also exhibit signs of hypoxemia (eg, stridor, respiratory distress, low pulse oximetry reading). Checking the calcium level so that effective treatment can begin is the highest priority. Educational objective: Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy. The nurse should monitor for signs and symptoms of tetany (tingling of hands, toes, and circumoral region; positive Trousseau or Chvostek sign), confirm with serum calcium results, and administer calcium gluconate as prescribed. Untreated clients can develop life-threatening laryngeal spasm.

The Nurse Assesses a Client Who Had a Thyroidectomy 8