A nurse is caring for a client who is 2 days postoperative following abdominal Surgery and requires enteral feedings.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at highest risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sunken fontanels and dry mucous membranes indicate moderate to severe dehydration, a serious complication of gastroenteritis in infants. This requires prompt fluid replacement (oral or IV) to prevent hypovolemic shock.
B. A mild fever and slightly elevated pulse are expected findings in gastroenteritis and not immediately concerning.
C. Decreased appetite and irritability are common, mild symptoms of illness but not critical.
D. A small fluid deficit (30 mL over 24 hours) is minimal in an infant and does not indicate severe dehydration.
Correct Answer is A
Explanation
A. Cumulative Index to Nursing and Allied Health Literature (CINAHL) is the most comprehensive nursing-specific electronic database, providing access to peer-reviewed nursing and allied health journals, evidence-based care sheets, research studies, and continuing education materials. It is the preferred source for nursing research and scholarly articles.
B. Agency for Healthcare Research and Quality (AHRQ) focuses on healthcare quality, safety, and outcomes but is not primarily a journal database; it provides guidelines and reports rather than comprehensive journal access.
C. Health Source offers general health-related articles, often intended for consumers or interdisciplinary audiences, but it lacks the depth and nursing focus found in CINAHL.
D. ProQuest is a large academic database that includes many disciplines; however, it is not as specific or detailed in nursing and allied health research as CINAHL.
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