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A nurse is caring for a client in a medical-surgical unit.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client is most at risk of developing

and
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}

The client is most at risk of developing atelectasis and paralytic ileus.

Rationale:

  1. Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.

  2. Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.
  • Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
  • Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
  • Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.


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Related Questions

Correct Answer is D

Explanation

A. "Submitting an incident report to risk management following a client fall." While this is important for safety and quality improvement, it is not a direct act of client advocacy.
B. "Documenting the effectiveness of pain medication in the client's health record." This is a critical part of nursing documentation but does not actively advocate for the client.
C. "Asking another nurse to check a medication calculation for a client." This promotes medication safety, but it is not an example of client advocacy.
D. "Informing the family of a deceased client of the client's wish to be an organ donor." Advocacy means ensuring the client’s wishes are honored, especially in sensitive situations like organ donation.

Correct Answer is ["A","B","C","D"]

Explanation

Cardiopulmonary:

Encourage deep-breathing exercises.
Check for pain.

Rationale:

Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.

Checking for pain is essential as the client has been prescribed PRN morphine for pain management.

"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.

Gastrointestinal:

Promote intake of oral fluids.
Apply barrier ointment after bowel movements.

Rationale:

Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.

Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.

"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.

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