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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 narrow base of support is recommended for effective lifting." A wide base of support provides more stability and balance, reducing the risk of injury.
B. "Make sure to bend at the waist when lifting objects more than 30 pounds." Bending at the knees, not the waist, helps maintain a neutral spine and prevents back strain.
C. "Use a twisting motion when moving objects to prevent back strain." Twisting while lifting can cause spinal injuries; instead, move the entire body by pivoting the feet.
D. "Stand close to a heavy object before attempting to lift it." Standing close to the object reduces strain on the back and improves control during lifting.

Correct Answer is B

Explanation

A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.

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