A nurse is monitoring the urinary output of a client who had a colon resection. Which 24-hour output total indicates oliguria?

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.

Choice A Reason:

Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.

Choice B Reason:

Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.

Choice C Reason:

Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.

Choice D Reason:

Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.