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A nurse is caring for a client in a medical-surgical unit.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client is most at risk of developing

and
Answer and Explanation

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

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.


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Related Questions

Correct Answer is D

Explanation

A. A community health nurse can provide education, medication management, and health monitoring, but they do not specifically focus on ADL assistance.
B. Respite care provides temporary relief for caregivers, but it does not directly help the client develop skills to maintain independence.
C. A dietitian focuses on nutritional needs and meal planning, but this does not directly address the increased difficulty with ADLs.

Correct Answer is A

Explanation

A. Consider gender and age when selecting an interpreter Cultural preferences may influence comfort and communication. For example, a client may feel more comfortable speaking with an interpreter of the same gender or age group.
B. Direct comments and questions to the interpreter The nurse should speak directly to the client, not the interpreter, to maintain engagement and respect.
C. Speak to the client in a loud voice Speaking louder does not improve comprehension and may come off as disrespectful. Clear, slow speech is more effective.
D. Ask a member of the client's family to serve as an interpreter Family members may omit or alter information and are not trained in medical terminology or confidentiality laws. A professional medical interpreter should be used.

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