A nurse is monitoring a client for complications following surgery.
Complete the following sentence by using the lists of options.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices:
- Pneumonia: The client has an elevated temperature, productive cough with thick white mucus, and mild crackles in the upper lobes. These findings, combined with recent immobility after surgery, indicate pulmonary infection risk.
- Respiratory findings: Crackles, cough, and sputum production directly support pneumonia as the complication most consistent with the client’s presentation.
Rationale for incorrect choices:
- Deep vein thrombosis: Although the client has nonpitting edema in the right leg, distal circulation is intact (pedal pulse 2+, capillary refill <2 seconds, foot warm). No calf pain, erythema, or unilateral swelling progression is reported.
- Urinary tract infection: The client voided a large amount of amber urine without dysuria, urgency, or suprapubic discomfort. No urinary abnormalities have been noted to suggest UTI.
- Nonpitting edema: This finding is expected locally after knee arthroplasty and does not indicate systemic infection.
- Elevated temperature: Fever alone is nonspecific and could be related to multiple postoperative risks; the respiratory findings provide more precise evidence for pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Cover your nose and mouth with a tissue when coughing.": Covering both the nose and mouth with a tissue prevents respiratory droplets from spreading into the environment, reducing transmission of influenza to others. Proper disposal of the tissue and hand hygiene should follow.
B. "If you are coughing frequently, you should wear gloves when preparing meals.": Gloves are not a primary measure for cough etiquette. Hand hygiene and avoiding food preparation while symptomatic are more effective in preventing the spread of influenza.
C. "Stay 2 feet away from others when coughing.": Droplet precautions for influenza recommend maintaining at least 3 feet of distance, and ideally up to 6 feet, to prevent exposure. Two feet is inadequate to protect others from respiratory droplets.
D. "Turn your head away when coughing.": Turning the head alone does not sufficiently contain respiratory secretions. Droplets can still disperse into the air, so using a tissue or the elbow crease is more effective.
Correct Answer is B
Explanation
A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.
B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.
C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.
D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.
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