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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 C

Explanation

A. Place multiple smoke detectors in the same area of the home. Smoke detectors should be placed in different areas, especially near bedrooms, in hallways, and on every level of the home, rather than clustering them in one area.
B. Change the batteries in smoke detectors every 2 years. Batteries should be changed at least once a year, and the smoke detector should be tested monthly to ensure functionality.
C. Cover the nose and mouth with a damp cloth before exiting a smoke-filled area. Using a damp cloth helps filter out some smoke and toxic fumes, reducing inhalation of harmful particles.
D. Open a window to let smoke out before leaving the home. Opening a window can increase oxygen flow, which may intensify the fire rather than help in an evacuation. Instead, the priority should be to evacuate immediately and call emergency services.

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

Explanation

Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.

Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.

Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.

Other Findings:

Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.

Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.

Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.

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