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 ["B","C"]
Explanation
A. Check for a disconnection in the ventilator tubing: A disconnection causes low-pressure alarms, not high-pressure alarms.
B. Check for a kink in the ventilator tubing: Kinked or obstructed tubing increases resistance to airflow, causing high-pressure alarms.
C. Suction the ET to remove secretions: Secretions in the airway increase airway resistance and pressure, leading to high-pressure alarms.
D. Assess the ET for a cuff leak: A cuff leak results in low-pressure alarms due to air escaping from the system.
E. Verify the placement of the ET: Malposition usually leads to decreased airflow or low-pressure alarms.
Correct Answer is ["B","C","E","G"]
Explanation
Rationale:
A. Urine ketones is negative; ketonuria would suggest dehydration or malnutrition, which are not evident here.
B. A severe, persistent headache unrelieved by acetaminophen is a classic warning sign of preeclampsia, indicating possible cerebral involvement due to increased blood pressure and endothelial dysfunction.
C. The client’s report of decreased fetal movement suggests uteroplacental insufficiency secondary to hypertension, which can lead to fetal hypoxia or growth restriction. This finding requires immediate evaluation of fetal well-being.
D. Gravida 3/parity 2 is expected and not a complication.
E. A BP of 162/112 mm Hg is markedly elevated, meeting the diagnostic criteria for severe preeclampsia (≥160 systolic or ≥110 diastolic). This finding indicates maternal and fetal risk for seizures, stroke, and placental abruption.
F. Respiratory rate of 16/min is within the normal range and not concerning.
G. A 3+ proteinuria indicates significant protein loss due to glomerular damage, another defining feature of preeclampsia. Combined with hypertension, this confirms a major obstetric emergency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.