Review the electronic health record. Complete the sentence using the drop-down lists. Based on the client's history and assessment findings, the client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Rationale for correct choices
• Atelectasis: Atelectasis is a common post-operative pulmonary complication, especially after orthopedic surgery, due to immobility, shallow breathing, and pain that limits deep inspiration. The client’s elevated respiratory rate (26 breaths/min) and low oxygen saturation (88% on room air) indicate decreased lung expansion.
• Alveolar collapse: Atelectasis occurs when alveoli fail to expand fully or collapse, impairing gas exchange. Post-operative pain and reluctance to ambulate contribute to inadequate lung inflation, promoting alveolar collapse. The client’s recent surgery, immobility, and shallow breathing make alveolar collapse the underlying mechanism of this pulmonary complication.
Rationale for incorrect choices
• Bowel obstruction: Although post-operative clients are at risk for gastrointestinal complications, there is no indication of abdominal distention, absent bowel sounds, vomiting, or constipation. The client’s main issue is respiratory compromise, making bowel obstruction unlikely in this scenario.
• Infection: While surgical site infection is a potential post-operative risk, the client currently shows no fever, wound drainage, or local inflammation. The immediate concern is hypoxia and respiratory compromise, so infection is less likely at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Rationale:
• Blood pressure of 120/82 mmHg: This blood pressure reading is within normal limits for an older adult. While hypotension or significant hypertension may indicate post-operative complications, a reading of 120/82 mmHg does not suggest immediate risk. It is unlikely to represent a complication and is considered stable.
• Body mass index of 26.6: A BMI of 26.6 falls into the overweight category but does not represent an acute post-operative complication. While elevated BMI may contribute to long-term risk factors, it does not indicate an immediate issue following knee replacement surgery.
• Respiration rate of 26 breaths per minute: Tachypnea in a post-operative client may indicate early hypoxia, pulmonary embolism, atelectasis, or pneumonia. After knee replacement surgery, immobility increases the risk of pulmonary complications. Monitoring respiratory status is critical because early detection of pulmonary compromise can prevent severe outcomes.
• Heart rate of 115 beats per minute: Tachycardia can be a compensatory response to hypoxia, pain, anxiety, or early infection. In post-operative clients, elevated heart rate may also indicate blood loss, dehydration, or pulmonary embolism. Continuous monitoring is warranted because persistent tachycardia can precede hemodynamic instability.
• Oxygen saturation of 88% on room air: An oxygen saturation below 90% is clinically significant hypoxemia. After orthopedic surgery, hypoxemia may result from anesthesia effects, atelectasis, or pulmonary embolism. Immediate interventions, such as supplemental oxygen and monitoring for respiratory compromise, are essential.
Correct Answer is ["A","B","E"]
Explanation
A. Size of the wound: Measuring the wound’s length, width, and depth provides objective data on the extent of tissue damage and progress of healing. Accurate measurement during inspection helps guide treatment and evaluate outcomes.
B. Stage of wound healing: Observing characteristics such as granulation tissue, epithelialization, or necrotic tissue allows the nurse to determine the wound’s healing stage. This assessment is essential for selecting appropriate interventions and monitoring progress.
C. Continence status: While continence can influence wound development, particularly in pressure injuries, it is part of the overall client assessment, not the visual inspection of the wound itself.
D. Changes in appetite: Appetite affects nutritional status and wound healing but is not directly assessed during the wound inspection phase. This information is gathered through history rather than visual assessment.
E. Location of the wound: Documenting the anatomical location helps in planning care, preventing pressure-related complications, and monitoring for healing. Accurate location assessment is a fundamental component of wound inspection.
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