A nurse is assessing a postoperative client for atelectasis. Which signs/symptoms of atelectasis require intervention? (Select all that apply)

Fever and tachycardia

Productive cough with green sputum

Chest pain and increased respiratory rate

Diminished breath sounds and dyspnea

Purulent drainage

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Fever and tachycardia indicate systemic inflammation in atelectasis, where collapsed alveoli reduce gas exchange, causing hypoxia. Tachycardia compensates for low oxygen, while cytokines from lung collapse trigger fever. These signs necessitate intervention like incentive spirometry to re-expand lungs, preventing complications such as pneumonia or sepsis, which worsen respiratory distress.

Choice B reason: Productive cough with green sputum suggests a bacterial infection, like pneumonia, rather than atelectasis alone. Atelectasis may predispose to infection by impairing mucociliary clearance, but green sputum indicates a secondary process requiring antibiotics, not primary atelectasis interventions like lung re-expansion, making this choice less urgent.

Choice C reason: Chest pain and increased respiratory rate are critical atelectasis symptoms. Pain arises from pleural irritation due to collapsed lung segments, while tachypnea compensates for hypoxia from reduced alveolar ventilation. These indicate significant respiratory compromise, requiring urgent interventions like chest physiotherapy or deep breathing to restore lung volume.

Choice D reason: Diminished breath sounds and dyspnea are hallmark atelectasis signs, reflecting collapsed alveoli and reduced air entry. Dyspnea results from impaired gas exchange, causing hypoxia and hypercapnia. Immediate interventions like positive pressure ventilation or incentive spirometry are needed to re-expand lungs, preventing further respiratory deterioration and ensuring adequate oxygenation.

Choice E reason: Purulent drainage is not typical of atelectasis but suggests an infectious process like an abscess or empyema. While atelectasis can trap secretions, predisposing to infection, purulent drainage requires specific treatments like antibiotics or drainage, not atelectasis-focused interventions like lung re-expansion, making this an incorrect choice for intervention.

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Correct Answer is B

Explanation

Choice A reason: Oxygen and suction equipment support respiratory function but are not the priority for opioid-induced respiratory depression from morphine. Lethargy and low respiratory rate (8 breaths/min) indicate overdose, requiring naloxone to reverse opioid effects first, as hypoxia can persist without addressing the primary cause.

Choice B reason: Naloxone, an opioid antagonist, reverses morphine-induced respiratory depression and lethargy. A respiratory rate of 8 breaths/min signals overdose, risking hypoxia and brain damage. Naloxone restores normal respiration by blocking opioid receptors, making it critical to have readily available for immediate administration in this scenario.

Choice C reason: IV fluids may support blood pressure but are not the priority for opioid-induced respiratory depression. Lethargy and low respiratory rate indicate morphine toxicity, requiring naloxone to reverse effects. Fluids address secondary issues like hypovolemia, not the primary concern of respiratory compromise in this case.

Choice D reason: A blood pressure monitor is unnecessary, as the client’s blood pressure (118/66) is stable. The critical issue is respiratory depression and lethargy from morphine, requiring naloxone. Monitoring blood pressure is secondary to addressing life-threatening respiratory compromise caused by opioid overdose in this postoperative client.

A. Answer the client’s questions B. Request that the surgeon come and answer the questions C. Place the consent form in the client’s medical record D. Notify the nurse manager of the client’s questions

Correct Answer is B

Explanation

Choice A reason: Answering questions is appropriate if within the nurse’s scope, but surgical risks and benefits require detailed, procedure-specific knowledge from the surgeon. Incorrect answers risk misinforming the client, affecting consent validity, making this less appropriate than consulting the surgeon for accurate information.

Choice B reason: Requesting the surgeon ensures the client receives accurate, procedure-specific information on risks and benefits, critical for informed consent. The surgeon’s expertise addresses complex questions, ensuring legal and ethical standards, making this the most appropriate action for post-consent clarification in this surgical scenario.

Choice C reason: Placing the consent form in the medical record is routine but does not address the client’s questions. Failing to clarify risks and benefits may invalidate informed consent, risking ethical and legal issues, making this action inappropriate as a response to the client’s immediate concerns.

Choice D reason: Notifying the nurse manager escalates the issue unnecessarily, as the surgeon is the appropriate expert for surgical risks and benefits. This delays resolution, potentially compromising informed consent, making it less appropriate than involving the surgeon for accurate, procedure-specific information.

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A nurse is assessing a postoperative client for atelectasis. Which signs/symptoms of atelectasis require intervention? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Correct Answer is B

Explanation

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