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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 B

Explanation

Rationale:
A. Use a 3 mL syringe to flush the PICC following infusions: A syringe smaller than 10 mL creates excessive pressure, which can damage the catheter. A 10 mL syringe or larger should always be used to flush a PICC to maintain catheter integrity.

B. Assess the PICC infusion system systematically: Systematic assessment of the PICC line, including the site, tubing, and connections, is essential for detecting complications such as infiltration, infection, or occlusion. This promotes safe and effective use of the catheter.

C. Change the needleless connector device on the IV tubing after each infusion: The needleless connector device does not need to be changed after each infusion. It is typically changed every 7 days or if contamination, leakage, or other issues are noted.

D. Provide daily dressing changes to the PICC insertion site: PICC dressings should be changed every 7 days if using a transparent dressing, or sooner if the dressing becomes damp, loose, or visibly soiled. Daily dressing changes increase infection risk unnecessarily.

Correct Answer is D

Explanation

Rationale:
A. Decreased calcium levels: Hypocalcemia may cause neuromuscular symptoms such as tetany or tingling but is not associated with exophthalmos (protruding eyes). Calcium imbalance does not typically cause changes in eye appearance.

B. Decreased somatotropin levels: Somatotropin (growth hormone) deficiency may lead to growth delay or reduced muscle mass, but it is not associated with changes in orbital appearance. Protruding eyes are unrelated to growth hormone levels.

C. Increased glucose levels: Elevated glucose is characteristic of diabetes mellitus and may lead to complications like neuropathy or retinopathy, but it does not cause eye protrusion.

D. Increased T4 levels: Elevated thyroxine (T4) is seen in hyperthyroidism, particularly in Graves' disease, which is strongly associated with exophthalmos. The protrusion results from inflammation and edema of orbital tissues, a hallmark of this thyroid disorder.

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