A patient who had thyroid surgery reports perioral tingling and develops carpopedal spasm. The patient is awake and breathing normally. What should the nurse do first?
Correct answer: A. Assess the airway and place the patient on cardiac monitoring
- A. Assess the airway and place the patient on cardiac monitoring
- B. Encourage the patient to walk to reduce muscle stiffness
- C. Give oral calcium without checking the prescription
- D. Document the symptoms and reassess after the next meal
Explanation
These findings suggest acute hypocalcaemia, which can progress to laryngospasm and cardiac dysrhythmias. Immediate airway assessment and cardiac monitoring identify deterioration while urgent treatment is arranged.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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