A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?

Choice A reason:

Pneumothorax, a collapsed lung, can indeed cause shortness of breath and dyspnea. However, it is typically associated with a sudden onset of these symptoms following a chest injury or spontaneously in the case of a ruptured air blister. In the context of a femoral head fracture, pneumothorax is less likely unless there was additional trauma to the chest area.

Choice B reason:

Pneumonia is an infection of the lungs that leads to inflammation of the air sacs, causing them to fill with fluid or pus. Symptoms include cough with phlegm, fever, chills, and difficulty breathing. While pneumonia could cause dyspnea, it usually develops due to an infectious process rather than directly from a femoral head fracture.

Choice C reason:

Airway obstruction involves a blockage that prevents air from passing freely to the lungs. It can be caused by foreign objects, swelling due to allergic reactions, or other medical conditions. The symptoms of airway obstruction include difficulty breathing, wheezing, and potential changes in skin color. However, airway obstruction is not commonly a direct complication of a femoral head fracture.

Choice D reason:

Fat embolism syndrome is a serious condition that occurs when fat globules enter the bloodstream and lodge within the pulmonary vasculature, leading to respiratory distress. It is a known complication following long bone fractures, such as the femur, and presents with symptoms like shortness of breath, hypoxemia, and neurological manifestations. Given the recent femoral head fracture and the symptoms reported, fat embolism syndrome is the most likely diagnosis.

Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.

Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.

Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.

Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.