A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
Atelectasis
Rales
Rhonchi
Pneumothorax
The Correct Answer is A
A. Atelectasis. Atelectasis is the collapse of alveoli due to hypoventilation, which commonly occurs postoperatively, especially in the lung bases.
B. Rales. Rales (crackles) are abnormal lung sounds associated with fluid in the alveoli, commonly seen in conditions like pneumonia or pulmonary edema, not atelectasis.
C. Rhonchi. Rhonchi are low-pitched sounds caused by mucus in the airways, often seen in chronic bronchitis or COPD.
D. Pneumothorax. Pneumothorax presents with absent breath sounds on one side, not bilaterally in the lung bases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. When still conscious, participate in marking the surgical site. The surgical site marking should be done with patient participation before anesthesia to confirm accuracy and prevent wrong-site surgery.
B. Have a photograph of the surgical site in the medical record. Photographs are not a standard requirement for surgical verification.
C. Have the unit nurse confirm their identity. Identity confirmation is necessary but not sufficient to prevent wrong-site surgery. Marking the site is the key step.
D. Verbally state the location of the surgical site and the expected procedure. Verbal confirmation is important but should be combined with physical marking of the site to ensure accuracy.
Correct Answer is D
Explanation
A. List the patient off the unit on the computer. Listing the patient off the unit in the computer is important for tracking, but this is not the most immediate priority when transporting the patient. Verifying the patient's identity is more crucial to prevent errors in patient care.
B. Tell the family how to get to the surgical waiting room. While it is helpful to guide the family to the surgical waiting room, the nurse's primary responsibility when the transport person arrives is to ensure the patient is correctly identified and safely transferred.
C. Assist with the transfer of the patient to the stretcher. Assisting with the transfer is important for patient safety, but the most important step is verifying the patient's identity to ensure the correct procedure is being performed.
D. Verify the patient's ID number with the medical record and transport slip. The most important task when the transport person arrives is to verify the patient's identity to prevent errors. The nurse must confirm the patient’s identity by checking the ID number against the medical record and transport slip before the patient is transferred to avoid any mistakes.
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