A nurse is caring for a 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":"C"}
The client is at risk for developing Pneumonia, Deep vein thrombosis, and Pressure ulcers
Choice A: Pneumonia
Reason: Postoperative patients, especially those who have undergone abdominal surgery, are at a higher risk of developing pneumonia. This is due to the fact that pain and discomfort can prevent them from taking deep breaths and coughing effectively, which are essential actions to clear the lungs of secretions. The nurse’s notes indicate that the client is refusing to turn and cough due to pain, which further increases the risk of pneumonia. The use of splinting with a pillow when coughing is a technique to help reduce pain and encourage effective coughing, but if the client refuses to comply, the risk remains high.
Choice B: Deep Vein Thrombosis (DVT)
Reason: Deep vein thrombosis is a significant risk for postoperative patients, particularly those who are immobile. The client in this scenario has refused to wear intermittent pneumatic compression devices, which are designed to prevent DVT by promoting blood circulation in the legs. Immobility and the lack of these devices increase the risk of blood clots forming in the deep veins of the legs. If a clot forms and travels to the lungs, it can cause a life-threatening pulmonary embolism. The nurse’s notes emphasize the importance of these devices, but the client’s refusal to use them puts them at a higher risk of developing DVT.
Choice C: Pressure Ulcers
Reason: Pressure ulcers, also known as bedsores, are a common complication for patients who are immobile for extended periods. The client’s refusal to change positions increases the risk of pressure ulcers developing on areas of the body that are in constant contact with the bed. These ulcers can be painful and lead to serious infections if not managed properly. Regular turning and repositioning are crucial in preventing pressure ulcers, and the nurse’s notes highlight the importance of this practice.
Choice D: Urinary Retention
Reason: While urinary retention can be a postoperative complication, it is less likely in this scenario because the client has a Foley catheter in place, which is draining to a bedside bag. The catheter helps to ensure that the bladder is emptied regularly, reducing the risk of urinary retention. Therefore, this is not one of the primary risks for this client based on the provided information.
Choice E: Hemorrhage
Reason: Hemorrhage, or excessive bleeding, is a potential risk after any surgery, including a total abdominal hysterectomy. However, the nurse’s notes indicate that the abdominal dressing is dry and intact, and only scant vaginal bleeding has been observed. This suggests that there is no significant bleeding at this time. While hemorrhage is always a concern, the current observations do not indicate an immediate risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Supported Sims: The Supported Sims position involves lying on one side with the lower arm behind the back and the upper thigh flexed. This position is not typically recommended for postoperative cholecystectomy patients as it does not provide optimal support for breathing and comfort.
Choice B reason:
Semi-Fowler’s: The Semi-Fowler’s position, where the head of the bed is elevated to about 30-45 degrees, is ideal for postoperative cholecystectomy patients. This position helps facilitate breathing, reduces the risk of aspiration, and promotes comfort by reducing tension on the abdominal muscles.
Choice C reason:
Dorsal recumbent: The Dorsal recumbent position involves lying flat on the back with knees bent and feet flat on the bed. While this position can be used for certain procedures, it is not the most comfortable or beneficial for postoperative cholecystectomy patients as it can increase abdominal pressure and discomfort.
Choice D reason:
Prone: The Prone position, where the patient lies flat on their stomach, is not suitable for postoperative cholecystectomy patients. This position can cause discomfort and does not support optimal breathing or reduce abdominal tension.
Correct Answer is D
Explanation
Choice A reason: Airborne
Airborne precautions are used for diseases that are transmitted through tiny airborne particles that can remain suspended in the air and be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. These diseases can spread over long distances and through ventilation systems. Pertussis, however, is not transmitted via airborne particles but rather through larger respiratory droplets.
Choice B reason: Contact
Contact precautions are used for infections that are spread by direct or indirect contact with the patient or the patient’s environment. This includes infections like methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. diff). While contact precautions are important for preventing the spread of certain infections, pertussis is primarily spread through respiratory droplets, making droplet precautions more appropriate.
Choice C reason: Protective
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from potential infections. This type of precaution is not intended to prevent the spread of infections from the patient to others but rather to protect the patient from external sources of infection. Examples include patients undergoing chemotherapy or those with severe immunodeficiency. Pertussis does not require protective precautions as it is not about protecting the patient from others.
Choice D reason: Droplet
Droplet precautions are the appropriate transmission-based precautions for pertussis. Pertussis, also known as whooping cough, is spread through respiratory droplets that are produced when an infected person coughs, sneezes, or talks. These droplets can travel short distances and can infect others who are in close proximity. Droplet precautions include wearing a mask when within 3 feet of the patient, placing the patient in a private room if possible, and ensuring that the patient wears a mask if they need to be transported.
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