A nurse is caring for a client who is 2 days postoperative following abdominal Surgery and requires enteral feedings.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Rationale:
Aspiration: The client has high gastric residual volumes (220 mL at 0800, 280 mL at 0900) while receiving enteral feedings via NG tube. Delayed gastric emptying increases the risk that stomach contents could reflux and enter the lungs, causing aspiration pneumonia. Continuous monitoring and potentially holding or adjusting feedings are indicated.
Skin breakdown: The client is postoperative, has an NG tube, limited mobility, and is experiencing pain that may reduce movement. These factors, combined with urine output changes and potential incontinence, increase the risk for pressure ulcers and skin breakdown at pressure points.
Other risks such as bleeding, hyperglycemia, and urinary retention are less immediate given the client’s current assessment and lab/vital signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Advise the parent to avoid giving cow’s milk to the infant prior to 1 year of age: Cow’s milk should not be introduced before 12 months due to the risk of iron-deficiency anemia, gastrointestinal irritation, and inadequate nutrient composition.
B. Instruct the parent to give the infant water every 3 hr between feedings: Water is not routinely needed in infants under 6 months; breast milk or formula provides adequate hydration.
C. Recommend the parent mix the milk with rice cereal for feedings: Mixing cereal with cow’s milk does not make it appropriate for infants and increases the risk of nutrient imbalance.
D. Instruct the parent to give 5 mcg of vitamin D daily: Vitamin D supplementation is appropriate for breastfed infants, but this does not address the concern about cow’s milk.
Correct Answer is D
Explanation
A. Pain is expected post-tonsillectomy, especially with swallowing, and does not indicate hemorrhage by itself.
B. Drowsiness could result from analgesics or anesthesia but is not a key indicator of bleeding.
C. Diminished breath sounds may indicate airway obstruction or aspiration but not specifically hemorrhage.
D. Frequent swallowing (or clearing the throat) is an early sign of postoperative bleeding, as the child swallows blood trickling down the throat rather than spitting it out. Other signs may include pallor, tachycardia, or bright red emesis.
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