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 A
Explanation
Choice A reason:
A sudden decrease in abdominal pain can indicate that the appendix has perforated. When the appendix bursts, the pressure is relieved, leading to a temporary reduction in pain. However, this is quickly followed by severe pain and signs of peritonitis, such as a rigid abdomen and high fever.
Choice B reason:
The absence of Rovsing’s sign is not a specific indicator of a perforated appendix. Rovsing’s sign is a clinical test used to diagnose appendicitis, where pain is elicited in the right lower quadrant when the left lower quadrant is palpated. Its absence does not necessarily indicate perforation.
Choice C reason:
A low-grade fever is a common symptom of appendicitis but does not specifically indicate perforation. A perforated appendix typically leads to a high fever due to the spread of infection within the abdomen.
Choice D reason:
A rigid abdomen is a sign of peritonitis, which can occur after the appendix has perforated. While this is an important symptom, the sudden decrease in pain followed by severe symptoms is more indicative of perforation.
Correct Answer is A
Explanation
Choice A reason: Office of Emergency Management (OEM)
The Office of Emergency Management (OEM) is typically the first agency to be notified in the event of a nonbiological or chemical incident. The OEM coordinates the local response efforts and ensures that all necessary resources and personnel are mobilized. They work closely with other local, state, and federal agencies to manage the incident effectively. The OEM’s role includes assessing the situation, providing information to the public, and coordinating evacuation or shelter-in-place orders if necessary.
Choice B reason: Federal Emergency Management Agency (FEMA)
The Federal Emergency Management Agency (FEMA) plays a crucial role in disaster response and recovery at the federal level. However, they are usually involved after the initial local response has been established. FEMA provides support and resources to local and state agencies, but the immediate notification should go to the local Office of Emergency Management.
Choice C reason: American Red Cross (ARC)
The American Red Cross (ARC) is a vital organization in disaster response, providing emergency shelter, food, and medical care. While they are an essential part of the response team, they are not typically the first agency to be notified. The ARC works in coordination with local emergency management agencies to support the affected community.
Choice D reason: U.S. Department of Homeland Security (DHS)
The U.S. Department of Homeland Security (DHS) oversees national efforts to protect against and respond to various threats, including chemical incidents. However, like FEMA, DHS is generally involved at a higher level of coordination and support. The immediate response is managed by local agencies, with DHS providing additional resources and expertise as needed
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