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A nurse is caring for a client.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing 

due to
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

The client is at risk for developing constipation due to opioid use.

Rationale:

  • Opioid Use → Constipation: Oxycodone, like other opioids, slows gastrointestinal motility, leading to constipation. This is a common postoperative concern, especially in clients with reduced mobility after a hip arthroplasty.

    • Confusion – No signs of mental status changes or factors like electrolyte imbalances.
    • Pressure Injuries – While immobility increases risk, this is not directly related to the provided findings.
    • Hypoglycemia – Blood glucose is normal, and there’s no IV dextrose mentioned.
    • Dysrhythmias – Potassium and sodium levels are within normal limits, reducing electrolyte-related cardiac risks.


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Related Questions

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}

Explanation

The client is most at risk of developing atelectasis and paralytic ileus.

Rationale:

  1. Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.

  2. Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.
  • Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
  • Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
  • Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.

Correct Answer is D

Explanation

A. "Apply intermittent suction for 20 to 30 seconds." –
Suctioning should be applied intermittently for no more than 10 to 15 seconds to prevent hypoxia and mucosal damage.
B. "Place the catheter in a location that is clean and dry for later use." –
A suction catheter should not be reused once it has been used; it should be discarded after a single use to prevent infection.
C. "Hold the suction catheter with the clean, nondominant hand." –
The dominant hand should remain sterile and be used to control the suction catheter, while the nondominant hand is used to handle nonsterile equipment.
D. "Use surgical asepsis when performing the procedure." –
Nasotracheal suctioning is a sterile procedure because it involves direct access to the lower airway, requiring surgical asepsis to reduce the risk of infection.

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