A nurse is caring for a client in an acute care setting.
The client is at risk for ________ as evidences by __________.
Complete the following sentence by using the list of options. Pick 2 choices.
Hypostatic pneumonia.
Anemia.
Fluid volume overload.
Immobility.
Calorie deficiency.
Correct Answer : A,D
Hypostatic Pneumonia Hypostatic pneumonia is a type of pneumonia that occurs when fluid or secretions settle in the lower lobes of the lungs, typically due to a lack of movement or staying in one position for too long. In this case, the client has paraplegia, which is a form of significant immobility. This condition prevents the client from effectively clearing their airway and results in decreased lung expansion.
Analysis of Evidence The clinical findings on Day 2 clearly indicate a progression toward an infectious respiratory process caused by this immobility:
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Respiratory Status: The oxygen saturation has dropped from 95% to 89%, and the respiratory rate has increased from 20/min to 24/min (tachypnea).
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Symptoms: The client has transitioned from a simple cough to a productive cough and is now experiencing confusion, which is a common sign of hypoxia in clinical settings.
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Infection Markers: The client's temperature has risen to 38.4°C (101.1°F), and the WBC count is elevated at 12,500/mm³, indicating a systemic inflammatory response or infection.
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Tachycardia: The heart rate has increased to 105/min, which is a compensatory mechanism for decreased oxygenation and the presence of a fever.
While the client's Hgb is slightly low (11.0 g/dL), it does not explain the acute onset of fever, confusion, and productive cough. Furthermore, there are no signs of fluid volume overload (such as edema or high BP) or calorie deficiency that would trigger these specific respiratory and febrile symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.
Choice B rationale:
Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.
Choice C rationale:
Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.
Choice D rationale:
Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.
Correct Answer is A
Explanation
The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.
Choice A rationale:
Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.
Choice B rationale:
While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.
Choice C rationale:
Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.
Choice D rationale:
Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.
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