A nurse is caring for a client in an acute care setting.
Complete the following sentence by using the list of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The client is at risk for hypostatic pneumonia as evidenced by the client's immobility
Rationale
The combination of paraplegia (which leads to limited mobility) and symptoms such as productive cough, tachycardia, and confusion suggest a respiratory issue, likely hypostatic pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measuring gastric residual volumes every 4 hours is important to assess the client’s tolerance to the feeding and prevent aspiration.
B. Flushing with saline should only be done as necessary for medication administration and not routinely unless specified by protocol.
C. The rate of feeding should be adjusted based on the client’s tolerance and not increased arbitrarily.
D. The head of the bed should be maintained at 30–45° to reduce the risk of aspiration.
Correct Answer is B
Explanation
A. Epistaxis (nosebleeds) is not a common manifestation of hypovolemia. It is more typically associated with conditions like hypertension or nasal trauma.
B. Dizziness is a common symptom of hypovolemia due to reduced blood volume and decreased perfusion to the brain.
C. Shortness of breath is more likely to occur with conditions such as pulmonary edema or respiratory disorders, not hypovolemia.
D. Headache can occur in hypovolemia due to reduced blood flow, but dizziness is more directly related to the body's inability to compensate for low blood volume.
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