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 D
Explanation
A. Cardiogenic shock can cause elevated PAWP, but the primary underlying issue in that condition is left ventricular failure, which leads to poor cardiac output.
B. Hypotension generally correlates with low preload and decreased PAWP, not an increase.
C. Hypovolemia results in low PAWP due to decreased circulating volume and venous return.
D. An elevated PAWP (normal: 4–12 mm Hg) indicates increased left atrial pressure, which is commonly seen in left ventricular failure. This occurs when the left ventricle cannot pump blood effectively, causing blood to back up into the lungs and increasing pulmonary venous pressure.
Correct Answer is B
Explanation
A. While family support is important, the client’s autonomy and emotional state must be addressed first.
B. Offering a referral for counseling or to a support person (e.g., social worker, mental health professional, chaplain) acknowledges the client’s feelings and provides a pathway for discussing goals of care and coping strategies. This response is therapeutic and supports informed decision-making.
C. Dismissing the statement as anxiety minimizes the client’s distress.
D. Deferring the conversation can leave the client feeling unheard and unsupported at a critical time.
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