The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

Epiglottitis

Bronchospasm

Atelectasis

Croup

Answer and Explanation

The Correct Answer is C

Choice A reason: Epiglottitis is an acute bacterial infection causing epiglottal swelling, primarily in children, leading to airway obstruction. Postoperative pneumonia, caused by bacterial infection or aspiration, increases mucus production and impairs gas exchange but does not typically cause epiglottal inflammation. Assessing for epiglottitis is irrelevant, as it’s unrelated to pneumonia’s pathophysiology, which involves alveolar consolidation and impaired oxygenation.

Choice B reason: Bronchospasm involves airway constriction due to smooth muscle contraction, common in asthma or COPD. Postoperative pneumonia, characterized by alveolar infection and consolidation, reduces lung compliance and gas exchange but rarely causes bronchospasm. Assessing for bronchospasm is less relevant, as pneumonia primarily affects alveoli, not bronchial smooth muscle, making this an unlikely complication to monitor.

Choice C reason: Atelectasis, the collapse of alveoli, is a common postoperative complication, especially with pneumonia, due to mucus accumulation and reduced lung expansion. This impairs gas exchange, increasing hypoxia risk. Frequent assessment for atelectasis, indicated by diminished breath sounds and hypoxemia, is critical, as it exacerbates pneumonia’s effects on alveolar ventilation and requires interventions like deep breathing exercises.

Choice D reason: Croup is a viral infection causing laryngeal and tracheal swelling, primarily in children, leading to a barking cough. Postoperative pneumonia in adults involves bacterial alveolar infection, not upper airway inflammation. Assessing for croup is inappropriate, as it’s unrelated to pneumonia’s pathophysiology, which focuses on lower respiratory tract consolidation and impaired gas exchange.

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Correct Answer is A

Explanation

Choice A reason: Teaching calcium intake to prevent bone loss is primary prevention, aimed at reducing disease risk before it occurs. Calcium strengthens bone density, reducing osteoporosis risk by supporting osteoblast activity and mineralization. This proactive measure prevents bone loss in healthy individuals, addressing the physiological need for calcium to maintain skeletal integrity before pathology develops.

Choice B reason: Secondary prevention involves early detection of disease, like screening for osteoporosis via bone density scans. Teaching calcium intake aims to prevent bone loss before it occurs, not detect it. Calcium supports bone remodeling, but secondary prevention targets existing asymptomatic conditions, making this incorrect for a strategy focused on preventing initial bone loss.

Choice C reason: Tertiary prevention manages existing disease to prevent complications, like rehabilitation after an osteoporotic fracture. Teaching calcium intake prevents bone loss before disease onset, aligning with primary prevention. Calcium enhances bone strength, but tertiary prevention focuses on restoring function post-disease, not preventing initial bone density loss, making this incorrect.

Choice D reason: Residual prevention is not a recognized term in public health. Teaching calcium intake is primary prevention, as it promotes bone health to prevent osteoporosis. Calcium supports bone matrix formation, reducing fracture risk. Incorrect terms like residual prevention do not apply, as prevention levels are clearly defined as primary, secondary, or tertiary in medical practice.

A. Hypertension. B. A dysrhythmia. C. Tachycardia. D. Bradycardia.

Correct Answer is B

Explanation

Choice A reason: Hypertension is defined by elevated blood pressure, not an irregular heart rate. An irregular pattern at 72 bpm suggests a rhythm abnormality, not a pressure issue. Hypertension affects vascular resistance, not cardiac rhythm directly, making this incorrect for the observed finding, per cardiovascular physiology.

Choice B reason: A dysrhythmia is indicated by an irregular heart rate pattern at 72 bpm, as it reflects abnormal electrical conduction, such as atrial fibrillation or premature beats. Notifying the provider is appropriate, as dysrhythmias may impair cardiac output or indicate underlying pathology, requiring prompt evaluation, per cardiac monitoring protocols.

Choice C reason: Tachycardia is a heart rate above 100 bpm, not applicable to 72 bpm. The irregularity, not speed, is the concern. Tachycardia involves rapid but often regular rhythms, whereas this finding suggests a dysrhythmia, making this choice incorrect for the described clinical presentation, per cardiac assessment.

Choice D reason: Bradycardia is a heart rate below 60 bpm, not matching 72 bpm. The irregular pattern points to a dysrhythmia, not a slow rate. Bradycardia affects heart rate frequency, not rhythm irregularity, making this irrelevant to the finding, which requires rhythm-focused intervention, per cardiac physiology.

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The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching clients on the need for calcium intake to prevent bone loss. What level of prevention does this represent?

Correct Answer is A

Explanation

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

Correct Answer is B

Explanation

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