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 B
Explanation
A. An adolescent client with diabetes mellitus who is admitted for hyperglycemia: Diabetes can impair circulation and wound healing, but adolescents are generally mobile and able to reposition independently. Short-term hyperglycemia alone does not create sustained pressure over bony prominences. Mobility significantly reduces pressure injury risk.
B. A middle-aged adult client who is comatose following a stroke: Coma results in complete immobility, loss of protective reflexes, and inability to reposition or perceive discomfort. Prolonged pressure over bony areas compromises tissue perfusion and increases ischemic injury. Neurologic impairment and immobility place this client at the highest risk.
C. An older adult client who is recovering from a sinus infection: Advanced age can increase vulnerability to skin breakdown, but a sinus infection does not typically limit mobility or sensation. Clients who are alert and ambulatory can relieve pressure independently. Risk remains relatively low without immobility.
D. An adult client with a spinal cord injury who engages in daily physical therapy: Although spinal cord injury increases baseline risk due to sensory deficits, regular physical therapy promotes mobility, circulation, and pressure relief. Active repositioning and therapeutic movement reduce prolonged pressure exposure. Consistent mobility lowers overall risk.
Correct Answer is D
Explanation
A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Measles is not primarily spread through direct contact, so contact precautions alone are insufficient.
B. Standard: Standard precautions apply to all clients to prevent transmission of bloodborne and body fluid pathogens. While essential, standard precautions alone do not prevent airborne spread of highly contagious respiratory viruses like measles.
C. Droplet: Droplet precautions are used for pathogens transmitted via large respiratory droplets, such as influenza or pertussis. Measles virus is smaller than droplet size and can remain suspended in the air, so droplet precautions alone do not provide adequate protection.
D. Airborne: Measles is highly contagious via airborne transmission. Airborne precautions, including placement in a negative-pressure room and use of an N95 respirator by healthcare personnel, prevent inhalation of aerosolized virus particles. This is the required precaution for measles.
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