A nurse is caring for a 55-year-old client who is 2 hours postoperative after having a total abdominal hysterectomy.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}
Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.
Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.
Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.
Correct Answer is B
Explanation
A. Labrynthitis is an inner ear disorder that causes vertigo, tinnitus, and hearing loss, but it does not typically involve otorrhea (ear discharge) or the sudden resolution of ear pain.
B. A perforated tympanic membrane is characterized by a sudden relief of ear pain when the eardrum ruptures, often accompanied by otorrhea (discharge from the ear). This condition is typically the result of an infection that increases pressure in the middle ear until the eardrum bursts.
C. Meniere disease involves episodes of vertigo, tinnitus, and fluctuating hearing loss, but does not usually present with ear pain followed by discharge.
D. Otitis externa, or swimmer’s ear, involves inflammation of the ear canal with symptoms like pain, itching, and discharge, but does not cause the sudden resolution of pain following the onset of otorrhea.
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