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A nurse is monitoring a client for complications following surgery.

Exhibits

Complete the following sentence by using the lists of options.

The client is at greatest risk for developing

as evidenced by.
Answer and Explanation

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

Rationale for correct choices:

  • Pneumonia: The client has an elevated temperature, productive cough with thick white mucus, and mild crackles in the upper lobes. These findings, combined with recent immobility after surgery, indicate pulmonary infection risk.
  • Respiratory findings: Crackles, cough, and sputum production directly support pneumonia as the complication most consistent with the client’s presentation.

Rationale for incorrect choices:

  • Deep vein thrombosis: Although the client has nonpitting edema in the right leg, distal circulation is intact (pedal pulse 2+, capillary refill <2 seconds, foot warm). No calf pain, erythema, or unilateral swelling progression is reported.
  •  Urinary tract infection: The client voided a large amount of amber urine without dysuria, urgency, or suprapubic discomfort. No urinary abnormalities have been noted to suggest UTI.
  • Nonpitting edema: This finding is expected locally after knee arthroplasty and does not indicate systemic infection.
  • Elevated temperature: Fever alone is nonspecific and could be related to multiple postoperative risks; the respiratory findings provide more precise evidence for pneumonia.


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Related Questions

Correct Answer is B

Explanation

A. Head of the bed: Securing restraints to the head of the bed is unsafe because this part does not move with the client’s position changes. It can create tension, leading to injury or impaired circulation.

B. Moveable portion of the bed frame: The safest method is to secure restraints to a moveable part of the bed frame. This ensures the restraints move with the client when the bed position changes, preventing tightening or loosening that could cause harm.

C. Foot of the bed: Tying restraints to the foot of the bed can cause excessive length of restraint straps and increase the risk of entanglement or injury. It also does not provide stable, controlled positioning during movement.

D. Side rails closest to the restraints: Side rails are not stable anchoring points because they move up and down. Attaching restraints here increases the risk of injury if the side rail is lowered, as it could loosen or tighten the restraint unexpectedly.

Correct Answer is C

Explanation

A. Apply foot cream between the toes: Moisturizing between the toes can create a warm, moist environment that promotes fungal or bacterial infections. Foot cream should be applied to the tops and bottoms of the feet, avoiding spaces between the toes.

B. Use a pumice stone to soften calluses: Using a pumice stone can cause skin breaks or ulcers in clients with peripheral neuropathy due to reduced sensation. Callus management should be performed by a healthcare professional to prevent injury.

C. Inspect the feet daily using a mirror: Daily inspection helps identify cuts, blisters, or infections early, especially since clients with peripheral neuropathy may not feel injuries due to decreased sensation. Using a mirror allows visualization of hard-to-see areas such as the soles.

D. Round the toenail edges when clipping: Toenails should be trimmed straight across to prevent ingrown nails and reduce the risk of infection. Rounding the edges can increase the likelihood of nail problems in clients with neuropathy.

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