A nurse is caring for a client who is postoperative and has developed atelectasis.
Which of the following findings should the nurse expect?
Facial flushing.
Dry cough.
Decreasing respiratory rate.
Increasing dyspnea.
The Correct Answer is D
Choice A rationale:
Facial flushing. Facial flushing is not typically associated with atelectasis. Atelectasis is the collapse of a portion of the lung, which can lead to decreased oxygenation and respiratory distress but does not directly cause facial flushing. Flushing may be related to other factors such as fever or allergic reactions.
Choice B rationale:
Dry cough. A dry cough can be a common symptom of atelectasis. As the lung tissue collapses and airways become obstructed, it can lead to irritation and a dry, non-productive cough as the body attempts to clear the airway. So, a dry cough is an expected finding in a client with atelectasis.
Choice C rationale:
Decreasing respiratory rate. A decreasing respiratory rate is not typically associated with atelectasis. In fact, atelectasis often leads to an increased respiratory rate as the body tries to compensate for the reduced oxygen exchange. The patient may experience tachypnea (rapid breathing) as a result.
Choice D rationale:
Increasing dyspnea. Increasing dyspnea is a common and expected finding in a client with atelectasis. As lung tissue collapses and oxygen exchange is compromised, the patient will likely experience worsening shortness of breath. This is a concerning symptom and should be closely monitored, as it may indicate a need for intervention to improve lung expansion and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.
Choice B rationale:
Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.
Choice C rationale:
Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.
Choice D rationale:
Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.
Correct Answer is D
Explanation
Choice A rationale:
Skipping coffee on the morning of the exercise ECG stress test is a good idea as caffeine can affect heart rate and blood pressure, but it doesn't necessarily indicate the need for further instructions.
Choice B rationale:
Getting 8 hours of sleep the night before the test is a positive choice and promotes overall well-being, but it is not a specific indicator of needing further instructions for the test.
Choice C rationale:
Not smoking before the test is an appropriate action, as smoking can also affect heart rate and blood pressure during the test. However, it does not indicate a need for further instructions.
Choice D rationale:
Expecting to feel chest pain during an exercise ECG stress test is not correct and indicates a need for further instructions. Chest pain during the test can be a sign of cardiovascular issues and should be reported immediately.
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