A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Choice A Reason:

A client who is 3 days postoperative and has a nursing assistant helping him out of bed is at some risk for falls due to recent surgery and potential weakness. However, the presence of a nursing assistant reduces this risk significantly. Postoperative clients are often monitored closely and assisted with mobility to prevent falls.

Choice B Reason:

An adolescent client who has a leg fracture and has been using crutches for the past 2 weeks is at risk for falls due to the use of crutches and limited mobility. However, adolescents generally have better balance and coordination compared to older adults, and they adapt quickly to using mobility aids.

Choice C Reason:

An older adult client who is confused and has urinary frequency is at the greatest risk for falls. Confusion can lead to disorientation and poor judgment, increasing the likelihood of falls. Urinary frequency can cause the client to rush to the bathroom, further increasing fall risk. Older adults also tend to have decreased strength and balance, compounding the risk.

Choice D Reason:

A client with diabetes mellitus who has a leg ulcer is at risk for falls due to potential neuropathy and impaired mobility. However, this risk is generally lower compared to a confused older adult with urinary frequency. The leg ulcer may cause some mobility issues, but it does not typically lead to the same level of disorientation and urgency as urinary frequency.

Choice A Reason:

Atelectasis is a common postoperative complication, especially in patients who have undergone abdominal or thoracic surgery. It occurs when the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This condition can result from shallow breathing, pain, or immobility after surgery. The absence of breath sounds in the bases of the lungs is a key indicator of atelectasis. Preventive measures include encouraging deep breathing exercises, using incentive spirometry, and early mobilization of the patient.

Choice B Reason:

Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs, causing a blockage in one of the pulmonary arteries. While PE can present with symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, it is less likely to cause absent breath sounds in the lung bases. Instead, PE may lead to decreased oxygen levels and respiratory distress. Diagnosis typically involves imaging studies such as a CT pulmonary angiography.

Choice C Reason:

Arterial thrombus refers to a blood clot that forms in an artery, which can lead to tissue ischemia and infarction. This condition is more commonly associated with cardiovascular events such as myocardial infarction or stroke. It does not typically present with absent breath sounds in the lungs. Instead, symptoms may include pain, pallor, and loss of function in the affected area. Diagnosis and treatment focus on restoring blood flow to the affected tissues.

Choice D Reason:

Pneumonia is an infection of the lungs that can cause symptoms such as cough, fever, and difficulty breathing. While pneumonia can lead to abnormal breath sounds, such as crackles or wheezes, it is less likely to cause completely absent breath sounds in the lung bases. Pneumonia is usually diagnosed through clinical examination, chest X-rays, and sputum cultures. Treatment involves antibiotics and supportive care to manage symptoms.