A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Friction rub

Decreasing respiratory rate

Increasing dyspnea

Facial flushing

Answer and Explanation

The Correct Answer is C

A. Friction rub: A friction rub is usually associated with pleuritis, not atelectasis. Atelectasis involves the collapse of alveoli and does not produce this sound.

B. Decreasing respiratory rate: Atelectasis generally leads to an increased respiratory rate as the body compensates for decreased oxygenation.

C. Increasing dyspnea: Increasing dyspnea is common in atelectasis as collapsed alveoli reduce oxygen exchange, leading to shortness of breath and increased respiratory effort.

D. Facial flushing: Facial flushing is not typically associated with atelectasis; instead, atelectasis leads to signs of respiratory distress, such as dyspnea and possibly cyanosis.

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Correct Answer is D

Explanation

A. "This may mean that your liver is failing and you need immediate medical attention." This statement is misleading; orange-red urine is not typically a sign of liver failure, especially in the context of a urinary tract infection.

B. "This is an expected finding for someone with a diet high in red meat." While diet can affect urine color, red meat is not commonly associated with orange-red urine; this is not a relevant response given the client's context.

C. “This is a symptom that your urinary tract infection is worsening. I will notify the provider.” While it is important to monitor urinary tract infections, orange-red urine is more likely related to the use of phenazopyridine rather than a worsening infection.

D. “This is an expected finding if you are taking the over-the-counter medication, Phenazopyridine.” Phenazopyridine is known to cause orange-red discoloration of urine, and this statement provides reassurance to the client regarding their symptoms.

A. Perform passive range of motion exercises. B. Place pillows under the client's knees when in bed. C. Assess legs for redness. D. Apply elastic compression stockings E. Massage the calves every shift

Correct Answer is ["A","C","D"]

Explanation

A. Perform passive range of motion exercises. Passive range of motion exercises help maintain circulation and reduce venous stasis, which is crucial for preventing pulmonary embolism in clients who are immobile.

B. Place pillows under the client's knees when in bed. Placing pillows under the knees can actually promote venous stasis and increase the risk of a pulmonary embolism. It is better to keep the legs flat to encourage circulation.

C. Assess legs for redness. Regular assessment of the legs for redness, swelling, or warmth helps in the early detection of deep vein thrombosis (DVT), which can lead to pulmonary embolism if not addressed.

D. Apply elastic compression stockings. Elastic compression stockings promote venous return from the legs to the heart and help prevent DVT, thereby reducing the risk of pulmonary embolism.

E. Massage the calves every shift. Massaging the calves can dislodge a thrombus and potentially lead to a pulmonary embolism. Instead, interventions should focus on preventing thrombus formation.

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A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

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