A nurse is caring for a client who is experiencing impaired mobility.
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":"C","dropdown-group-2":"D"}
A. Diarrhea: Not relevant to the client's condition of impaired mobility and recent hip fracture.
B. Hypocalcemia: Not directly related to the client's current condition and symptoms.
C. Pulmonary embolism: The client is at risk due to limited mobility and signs of deep vein thrombosis.
D. Deep vein thrombosis: The client has symptoms such as a warm, reddened area on the calf, indicating a potential DVT.
E. Hypertension: The client's blood pressure is within normal limits, so this is not a primary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Storing oxygen tanks near sources of heat is dangerous. Oxygen should be stored in a cool, dry place away from heat sources and flammable materials to prevent the risk of fire or explosion.
B. Oxygen therapy should not be limited to periods of activity or exertion. For patients with COPD, continuous oxygen therapy is often necessary to maintain adequate oxygen saturation levels, even during sleep.
C. Adjusting the oxygen flow rate to the highest level can be harmful, especially in patients with COPD, as it may suppress their hypoxic drive to breathe. The flow rate should be prescribed and adjusted by the healthcare provider.
D. Continuous use of oxygen therapy, even during sleep, is essential for maintaining adequate oxygen saturation levels in patients with COPD. This helps prevent hypoxemia and ensures the patient receives the necessary oxygen support.
Correct Answer is A
Explanation
A. If there is no fluctuation in the water seal compartment, the first action should be to check for kinks, obstructions, or other issues in the tubing that might block air or fluid movement. Fluctuation (tidaling) is expected during respiration, and its absence may indicate a problem with the system or that the lung has fully re-expanded.
B. Notifying the healthcare provider immediately is not the first step. The nurse should first assess the chest tube system to determine if there is an issue that can be resolved without medical intervention.
C. Increasing the suction pressure on the chest tube is not appropriate without first identifying the cause of the lack of fluctuation. Adjusting suction may not address the underlying problem.
D. Continuing to monitor and reassess in 1 hour delays addressing the potential issue. Immediate assessment of the chest tube system is necessary to ensure proper functioning.
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