List four complications that C.P. is at risk for postoperatively. Describe actions you should
include in C.P.'s plan of care related to each complication.
What will be an ideal response?
Respiratory distress: Advise C.P. to talk as little as possible to prevent swelling; keep head of bed
(HOB) elevated, and apply an ice bag to her throat; instruct C.P. to notify you if she experiences
any signs and symptoms of airway obstruction (swelling or difficulty breathing). Frequently
assess respiratory rate and for signs of dyspnea and restlessness. Nebulizer equipment and
bronchodilators, corticosteroids, or racemic epinephrine can be ordered for standby at the
bedside.
Hypocalcemia (tetany or convulsions): Monitor calcium levels; keep an ampule of calcium gluconate
at the bedside to be used as prescribed; keep side rails up while in C.P. is in bed; note any
muscular irritability; test for tetany.
Hemorrhage at the surgical site: Visualize her neck and incision site when you take her VS, and
have her report any pressure sensation in her neck or throat. Confirm that an active type and
crossmatch is on file in the blood bank and that crossmatched blood is available as prescribed.
IV normal saline or lactated Ringer's solution should be available for initial management of
hemorrhage.
Injury to the laryngeal nerve: When C.P. does speak, you should note any voice changes that might
indicate injury to the laryngeal nerve.
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Your patient is in hypovolemic shock. You know that antidiuretic hormone (ADH) plays a role during hypovolemic shock. What assessment finding will you likely observe related to the role of the antidiuretic hormone (ADH) during hypovolemic shock?
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The student nurse observing a surgical procedure begins to feel lightheaded and nauseated. Which of the following should the student do at this time?
1. Tell someone she does not feel well. 2. Leave the operating room immediately. 3. Nothing since this feeling will pass. 4. Immediately sit down on the floor.