A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair.

The nurse should educate the client about the increased risk of which complication?

Skin breakdown.

Pneumonia.

Thrombosis.

Atelectasis.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While skin breakdown can occur due to prolonged bed rest, it is not directly related to shallow respirations and refusal to cough or get out of bed.
Choice B rationale
Pneumonia is a possible complication due to immobility and shallow breathing. However, it is not the most immediate risk for a postoperative client who is refusing to cough or get out of bed.
Choice C rationale
Thrombosis is a risk associated with immobility, but it is not directly related to shallow respirations.
Choice D rationale
Atelectasis, or the collapse of alveoli in the lungs, is a common complication after surgery due to shallow breathing and lack of movement. This condition leads to reduced or absent gas exchange, which can further complicate the client’s recovery.

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Correct Answer is A

Explanation

Choice A rationale
Restlessness in a client with a tracheostomy could indicate respiratory distress or hypoxia. It’s important for the nurse to further assess the client’s vital signs, oxygen saturation, and overall appearance.
Choice B rationale
A SaO2 of 92% on 40% humidified oxygen via tracheostomy collar is within the acceptable range for a client with a tracheostomy. However, it’s important to consider the client’s baseline SaO2 and any changes in their condition.
Choice C rationale
Scattered rhonchi throughout the lung fields could indicate secretions in the airways. However, this finding alone does not necessarily indicate a problem with the tracheostomy.
Choice D rationale
Suctioning of thin clear secretions from a tracheostomy is a routine part of tracheostomy care. This finding does not necessarily indicate a problem with the tracheostomy.

A. Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises. B. Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage. C. Potential Condition: Pulmonary edema. D. Potential Condition: Pneumonia.

Correct Answer is B

Explanation

Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.

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A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair. The nurse should educate the client about the increased risk of which complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?

Correct Answer is A

Explanation

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Correct Answer is B

Explanation

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In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.

A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair.

The nurse should educate the client about the increased risk of which complication?