A nurse is assessing a client who is 2 days postoperative and is auscultating their bilateral breath sounds. The nurse notes absent breath sounds in the bases. The nurse should suspect which postoperative complication is occurring in this client?
Atelectasis
Pulmonary embolism
Arterial thrombus
Pneumonia
The Correct Answer is A
Choice A Reason:
Atelectasis is a common postoperative complication, especially in patients who have undergone abdominal or thoracic surgery. It occurs when the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This condition can result from shallow breathing, pain, or immobility after surgery. The absence of breath sounds in the bases of the lungs is a key indicator of atelectasis. Preventive measures include encouraging deep breathing exercises, using incentive spirometry, and early mobilization of the patient.
Choice B Reason:
Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs, causing a blockage in one of the pulmonary arteries. While PE can present with symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, it is less likely to cause absent breath sounds in the lung bases. Instead, PE may lead to decreased oxygen levels and respiratory distress. Diagnosis typically involves imaging studies such as a CT pulmonary angiography.
Choice C Reason:
Arterial thrombus refers to a blood clot that forms in an artery, which can lead to tissue ischemia and infarction. This condition is more commonly associated with cardiovascular events such as myocardial infarction or stroke. It does not typically present with absent breath sounds in the lungs. Instead, symptoms may include pain, pallor, and loss of function in the affected area. Diagnosis and treatment focus on restoring blood flow to the affected tissues.
Choice D Reason:
Pneumonia is an infection of the lungs that can cause symptoms such as cough, fever, and difficulty breathing. While pneumonia can lead to abnormal breath sounds, such as crackles or wheezes, it is less likely to cause completely absent breath sounds in the lung bases. Pneumonia is usually diagnosed through clinical examination, chest X-rays, and sputum cultures. Treatment involves antibiotics and supportive care to manage symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Fiber is correct. Fiber is essential for maintaining healthy bowel elimination. It helps to add bulk to the stool and promotes regular bowel movements. There are two types of fiber: soluble and insoluble. Soluble fiber absorbs water and forms a gel-like substance, which helps soften the stool and make it easier to pass. Insoluble fiber adds bulk to the stool and helps it move through the digestive tract more quickly.
Choice B Reason:
Fat is incorrect. While fats are an important part of a balanced diet, they do not play a primary role in maintaining healthy bowel elimination. Fats are essential for energy and the absorption of fat-soluble vitamins, but they do not have the same effect on bowel movements as fiber.
Choice C Reason:
Protein is incorrect. Protein is crucial for building and repairing tissues, but it does not directly influence bowel elimination. A diet high in protein without adequate fiber can sometimes lead to constipation.
Choice D Reason:
Minerals are incorrect. Minerals are vital for various bodily functions, including bone health, fluid balance, and muscle function. However, they do not directly impact bowel elimination in the same way that fiber does.
Correct Answer is ["1"]
Explanation
We know:
- The prescribed dose is 25 mg.
- The available concentration is 125 mg per 5 mL.
Step 2 is to set up the calculation.
We will use the formula: (Desired Dose in mL) = (Prescribed Dose in mg × Volume Available in mL) ÷ Concentration Available in mg
Step 3 is to plug in the values into the formula.
(Desired Dose in mL) = (25 mg × 5 mL) ÷ 125 mg
Step 4 is to perform the multiplication first.
25 mg × 5 mL = 125
Step 5 is to perform the division.
125 ÷ 125 mg = 1 mL
Step 6 is the result.
The nurse should administer 1 mL per dose.
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