A nurse is caring for a client who is 2 hours postoperative after having a total abdominal hysterectomy.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}
The client is at risk for developing Pneumonia, Deep vein thrombosis, and Pressure ulcers
Choice A: Pneumonia
Reason: Postoperative patients, especially those who have undergone abdominal surgery, are at a higher risk of developing pneumonia. This is due to the fact that pain and discomfort can prevent them from taking deep breaths and coughing effectively, which are essential actions to clear the lungs of secretions. The nurse’s notes indicate that the client is refusing to turn and cough due to pain, which further increases the risk of pneumonia. The use of splinting with a pillow when coughing is a technique to help reduce pain and encourage effective coughing, but if the client refuses to comply, the risk remains high.
Choice B: Deep Vein Thrombosis (DVT)
Reason: Deep vein thrombosis is a significant risk for postoperative patients, particularly those who are immobile. The client in this scenario has refused to wear intermittent pneumatic compression devices, which are designed to prevent DVT by promoting blood circulation in the legs. Immobility and the lack of these devices increase the risk of blood clots forming in the deep veins of the legs. If a clot forms and travels to the lungs, it can cause a life-threatening pulmonary embolism. The nurse’s notes emphasize the importance of these devices, but the client’s refusal to use them puts them at a higher risk of developing DVT.
Choice C: Pressure Ulcers
Reason: Pressure ulcers, also known as bedsores, are a common complication for patients who are immobile for extended periods. The client’s refusal to change positions increases the risk of pressure ulcers developing on areas of the body that are in constant contact with the bed. These ulcers can be painful and lead to serious infections if not managed properly. Regular turning and repositioning are crucial in preventing pressure ulcers, and the nurse’s notes highlight the importance of this practice.
Choice D: Urinary Retention
Reason: While urinary retention can be a postoperative complication, it is less likely in this scenario because the client has a Foley catheter in place, which is draining to a bedside bag. The catheter helps to ensure that the bladder is emptied regularly, reducing the risk of urinary retention. Therefore, this is not one of the primary risks for this client based on the provided information.
Choice E: Hemorrhage
Reason: Hemorrhage, or excessive bleeding, is a potential risk after any surgery, including a total abdominal hysterectomy. However, the nurse’s notes indicate that the abdominal dressing is dry and intact, and only scant vaginal bleeding has been observed. This suggests that there is no significant bleeding at this time. While hemorrhage is always a concern, the current observations do not indicate an immediate risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While articulating expectations is important, the nurse’s response is more focused on addressing the client’s feelings and encouraging participation in therapy. Simply stating expectations without addressing the client’s emotions may not be as effective.
Choice B reason:
The nurse’s response demonstrates empathy by acknowledging the client’s feelings and gently guiding them towards participating in group therapy. This approach helps build trust and rapport, which are essential in therapeutic relationships, especially with clients exhibiting delusional behavior.
Choice C reason:
Setting limits on manipulative behavior is important, but in this context, the nurse’s response is more about encouraging participation and showing understanding rather than strictly setting limits.
Choice D reason:
Reflection involves mirroring the client’s feelings or statements to show understanding. While the nurse’s response does show understanding, it is not a direct example of reflection. The primary focus is on empathy and encouragement.
Correct Answer is A
Explanation
Choice A reason:
Obtaining a 12-lead ECG is crucial for a client with a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and an ECG can help detect these abnormalities early.
Choice B reason:
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase potassium levels and exacerbate hyperkalemia.
Choice C reason:
Asking the client to add citrus juices and bananas to her diet is also inappropriate. These foods are high in potassium and can worsen hyperkalemia.
Choice D reason:
While obtaining a blood sample for a serum sodium level can be part of the overall assessment, it is not the immediate priority. The primary concern with hyperkalemia is the risk of cardiac dysrhythmias, which makes obtaining a 12-lead ECG the most urgent action.
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