During a preoperative assessment, a nurse documents that the client has a history of vertigo and orthostatic hypotension. These findings place the client at high risk for which postoperative complication?
Delirium
Malnutrition
Pain
Falls
The Correct Answer is D
A. While older adults are at risk for postoperative delirium, vertigo and orthostatic hypotension are specifically vestibular and hemodynamic issues rather than primary cognitive risk factors. Delirium is more closely linked to polypharmacy, anesthesia effects, and sleep deprivation. Although physiological stress contributes to confusion, these specific findings more directly jeopardize physical stability and safety during mobilization.
B. Malnutrition is an assessment finding related to chronic dietary intake, metabolic demands, or malabsorption syndromes rather than acute balance or blood pressure fluctuations. Vertigo may cause temporary nausea, but it does not serve as a primary predictor for postoperative nutritional failure. The nurse should focus on the immediate physical dangers posed by the client's inability to maintain an upright, stable posture.
C. Postoperative pain is an expected outcome of surgical trauma and is influenced by the type of procedure and individual pain thresholds. A history of vertigo or orthostatic hypotension does not increase the physiological intensity or perception of surgical pain. These conditions are cardiovascular and neurological in nature, primarily affecting the client's coordination and autonomic response to changes in position.
D. Vertigo causes a sensation of spinning and impaired balance, while orthostatic hypotension leads to a sudden drop in blood pressure upon standing, causing dizziness or syncope. In the postoperative period, where anesthesia and analgesics further impair coordination, these preexisting conditions significantly escalate the risk of accidental falls. The nurse must implement strict fall precautions to ensure the client's safety during early ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Premedicating with diphenhydramine is an intervention used to prevent allergic transfusion reactions, such as urticaria or pruritus, in patients with a known history of sensitivity. It does not address ABO compatibility or the safety of the specific blood type being administered. Since O negative blood is the universal donor, no allergic reaction related to type mismatch is anticipated in this scenario.
B.Notifying the provider and blood bank is unnecessary because there is no error in the blood type provided. O negative blood lacks A, B, and Rh antigens on the erythrocyte surface, making it safe for a client with A positive blood. Routine communication is essential, but alerting these departments for a compatible transfusion would be an inappropriate use of clinical resources.
C.Extending the infusion time to 5 hours is clinically contraindicated, as blood components must be fully administered within 4 hours to prevent bacterial proliferation. Prolonging the transfusion beyond this safety window increases the risk of septic reactions and degrades the quality of the red cells. Standard protocols require completion within 2 to 4 hours to maintain the integrity of the PRBCs.
D.The nurse should administer the blood as ordered because O negative is the universal donor and is fully compatible with an A positive recipient. The recipient's antibodies will not react with the O negative donor cells because those cells lack the A, B, and Rh antigens. This is a safe and standard pharmacological practice when the specific blood type is unavailable or in emergency clinical situations.
Correct Answer is A
Explanation
A.Baked chicken breast prepared without salt is a high-protein, low-sodium option that supports the nutritional needs of a client with liver impairment. It provides essential amino acids necessary for albumin synthesis while avoiding the hidden sodium found in processed meats. This choice helps manage the osmotic pressure needed to reduce ascites and peripheral edema without contributing to further fluid volume excess.
B.Spaghetti with tomato sauce, especially if the sauce is commercially prepared, often contains high levels of sodium used as a preservative and flavor enhancer. High sodium intake in clients with hepatic dysfunction triggers the renin-angiotensin-aldosterone system, leading to significant water retention and worsening of portal hypertension. The nurse should advise the client to choose fresh, unprocessed ingredients to maintain a strict low-sodium profile.
C.A bowl of ice cream contains significant amounts of sugar and saturated fats, which can exacerbate underlying metabolic issues or non-alcoholic fatty liver disease. While it may not be as high in sodium as canned goods, it does not provide the lean protein required for hepatic cellular repair and maintenance of oncotic pressure. The nurse should prioritize nutrient-dense meals that specifically address the sodium restriction and protein requirements.
D.Canned soup is one of the most concentrated sources of sodium in the modern diet, often exceeding 800 mg per serving. Consuming such high levels of salt would cause rapid fluid accumulation in a client with liver impairment, potentially leading to respiratory distress or severe abdominal tension from ascites. The nurse must educate the client to avoid canned or highly processed foods to prevent acute fluid overload.
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