A nurse is caring for a 55-year-old client who is 2 hours postoperative after having a total abdominal hysterectomy.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}
Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.
Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.
Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While the time of the burn can provide information about the potential progression of injury, it is not the primary factor in determining the severity of the burn.
B. The depth of the burn is crucial for assessing the severity of the injury as it directly impacts the treatment required and the potential for complications. Depth determines whether the burn is superficial, partial-thickness, or full-thickness.
C. The cause of the burn is relevant for understanding the mechanism of injury but does not directly affect the assessment of burn severity.
D. The location of the burn is important for assessing potential complications and functional impairment but is secondary to the depth of the burn when determining overall severity.
Correct Answer is A
Explanation
A. Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
B. While blood pressure is important to monitor, it is secondary to assessing anticoagulant use since high blood pressure alone does not contraindicate t-PA administration.
C. A complete neurologic assessment is important for determining the extent of the stroke but is not the immediate priority before administering t-PA.
D. While treatment for peptic ulcer disease is relevant, it is not directly related to the immediate risk factors for t-PA administration compared to anticoagulant use.
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