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A nurse is caring for a client who is 2 days postoperative following abdominal Surgery and requires enteral feedings.

Exhibits

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

The client is at highest risk for developing

and .
Answer and Explanation

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

Rationale:

Aspiration: The client has high gastric residual volumes (220 mL at 0800, 280 mL at 0900) while receiving enteral feedings via NG tube. Delayed gastric emptying increases the risk that stomach contents could reflux and enter the lungs, causing aspiration pneumonia. Continuous monitoring and potentially holding or adjusting feedings are indicated.

Skin breakdown: The client is postoperative, has an NG tube, limited mobility, and is experiencing pain that may reduce movement. These factors, combined with urine output changes and potential incontinence, increase the risk for pressure ulcers and skin breakdown at pressure points.

Other risks such as bleeding, hyperglycemia, and urinary retention are less immediate given the client’s current assessment and lab/vital signs.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Hemoglobin 18.0 g/dL

Preeclampsia: Mild hemoconcentration can occur due to third spacing and fluid shift.

HELLP Syndrome: HELLP is more characterized by low hemoglobin due to hemolysis rather than high hemoglobin.

Alanine aminotransferase (ALT) 40 units/L

Preeclampsia: Liver enzymes can be mildly elevated in severe preeclampsia, but not as prominent as in HELLP.

HELLP Syndrome: Consistent finding. Elevated ALT reflects liver dysfunction, one of the hallmark components of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets).

Platelet count 98,000/mm³

Preeclampsia: Thrombocytopenia can occur in severe preeclampsia. Platelets <100,000/mm³ is concerning for progression to severe disease.

HELLP Syndrome: Consistent finding. Low platelets are a key diagnostic criterion of HELLP syndrome.

Blood Pressure 162/112 mm Hg

Preeclampsia: Consistent finding. Hypertension (≥140/90 mm Hg) is the primary diagnostic criterion for preeclampsia.

HELLP Syndrome: Often present with elevated blood pressure as well. HELLP is a variant of severe preeclampsia so elevated BP is common.

Correct Answer is A

Explanation

A. The ointment should be spread in a thin, even layer on a hairless area (e.g., chest, upper arm) using the applicator to ensure consistent absorption.

B. The ointment should not be massaged, as this can alter absorption rate and cause hypotension.

C. Application sites should be rotated to prevent irritation; the forearm is not optimal due to thinner skin.

D. The prescription schedule depends on provider instructions, typically every 6–12 hours with a nitrate-free period to prevent tolerance.

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