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A nurse is collecting data on a client who is one day postoperative. The nurse should recognize which of the following findings is a manifestation of atelectasis?

Pedal edema

Dysphagia

Distended neck veins

Dyspnea

Answer and Explanation

The Correct Answer is D

A. Pedal edema is related to fluid retention or circulatory issues, not atelectasis.

B. Dysphagia, or difficulty swallowing, is not typically associated with atelectasis.

C. Distended neck veins are a sign of increased central venous pressure, not atelectasis.

D. Dyspnea, or difficulty breathing, is a common sign of atelectasis, which is the collapse of part or all of a lung, leading to impaired gas exchange.

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Correct Answer is D

Explanation

A. Restlessness is a sign of hypoxia, indicating that oxygenation might still be inadequate.

B. A heart rate of 110/min suggests tachycardia, which can also be associated with ongoing hypoxia.

C. A respiratory rate of 28/min is elevated and may indicate continued respiratory distress or hypoxia.

D. Pink mucous membranes are a sign of adequate oxygenation and indicate that the supplemental oxygen is effective in resolving the hypoxia.

A. "Activation of the inflammatory cascade causes increased perfusion." B. The major organ prone to injury during SIRS is the heart." C. Spleen dysfunction causes blood clotting issues." D. "A deregulated cytokine storm causes an inflammatory response."

Correct Answer is D

Explanation

A. Activation of the inflammatory cascade in SIRS typically leads to decreased perfusion and tissue damage due to widespread inflammation and capillary leakage.

B. SIRS can affect multiple organs, but it is particularly known for impacting the lungs and kidneys rather than the heart.

C. While SIRS can involve coagulation issues, these are not specifically due to spleen dysfunction but rather to the widespread inflammatory response.

D. SIRS is driven by a deregulated cytokine storm, which leads to an excessive and uncontrolled inflammatory response, potentially resulting in multiple organ failure.

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A nurse is collecting data on a client who is one day postoperative. The nurse should recognize which of the following findings is a manifestation of atelectasis?

Nursing Test Bank

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