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A nurse is caring for a client who is postoperative following a thoracotomy with lung resection 24 hr ago.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

due to postoperatively.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale:

  • Pneumothorax: Pneumothorax presents with sudden respiratory distress, unilateral absent breath sounds, or tracheal deviation. This client has bilateral breath sounds and a functioning chest tube, making this condition less likely.
  • Atelectasis: Atelectasis is a common complication after thoracic surgery, especially when the client is hypoventilating. Shallow breathing, decreased oxygen saturation, crackles, and refusal to use the incentive spirometer all point to developing alveolar collapse.
  • Pulmonary embolism: PE often presents with sudden chest pain, dyspnea, and possibly hemoptysis or hypotension. This client’s symptoms have developed gradually and lack hallmark features of PE.
  • Sanguineous chest tube drainage: This is expected within 24–48 hours post-thoracotomy and does not indicate a specific respiratory complication unless the volume is excessive or suddenly increases.
  • Morphine use for pain management: Morphine can contribute to shallow respirations but is a routine part of postoperative care. It is not the most direct factor responsible for the client’s worsening pulmonary status.
  • Failure to use the incentive spirometer: This is a direct contributor to hypoventilation and secretion retention, leading to atelectasis. The client’s discomfort has prevented lung expansion, setting the stage for alveolar collapse and impaired gas exchange.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. Increased pigmentation: Triamcinolone, a topical corticosteroid, is not known to cause increased skin pigmentation. In some cases, prolonged use can lead to hypopigmentation, especially in clients with darker skin tones.

B. Localized hair loss: Hair loss is not commonly associated with triamcinolone use. In fact, some corticosteroids may lead to localized hair growth due to their effects on the skin and follicles.

C. Thinning of the skin: Prolonged use of topical corticosteroids like triamcinolone can lead to skin atrophy. This manifests as thinning of the skin, increased fragility, and a higher risk of bruising or tearing with minimal trauma.

D. Increased sensitivity to the sun: Photosensitivity is not a typical side effect of triamcinolone. Sun protection is generally recommended for healthy skin care, but triamcinolone does not specifically increase sun sensitivity.

Correct Answer is D

Explanation

Rationale:
A. Decreased WBC count: Bacterial meningitis causes an inflammatory response, leading to an increased WBC count in the cerebrospinal fluid (CSF), not a decrease. Elevated WBCs indicate the body is fighting infection in the central nervous system.

B. Increased glucose: CSF glucose levels are typically decreased because bacteria consume glucose and impair its transport across the blood-brain barrier. The presence of leukocytes and pathogens in the CSF also contributes to glucose depletion. Elevated glucose is not characteristic of this condition.

C. Clear cerebrospinal fluid: CSF in bacterial meningitis is usually cloudy or turbid due to the accumulation of white blood cells, protein, and bacteria. The change in appearance reflects the severity of the infection and is one of the classic diagnostic signs. Clear CSF would be more consistent with normal or viral findings.

D. Increased protein: A hallmark of bacterial meningitis is elevated CSF protein levels due to increased permeability of the blood-brain barrier and the presence of bacterial and inflammatory proteins. This is an expected finding.

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