A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?
Friction rub
Decreasing respiratory rate
Increasing dyspnea
Facial flushing
The Correct Answer is C
A. Friction rub: A friction rub is usually associated with pleuritis, not atelectasis. Atelectasis involves the collapse of alveoli and does not produce this sound.
B. Decreasing respiratory rate: Atelectasis generally leads to an increased respiratory rate as the body compensates for decreased oxygenation.
C. Increasing dyspnea: Increasing dyspnea is common in atelectasis as collapsed alveoli reduce oxygen exchange, leading to shortness of breath and increased respiratory effort.
D. Facial flushing: Facial flushing is not typically associated with atelectasis; instead, atelectasis leads to signs of respiratory distress, such as dyspnea and possibly cyanosis.
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Correct Answer is D
Explanation
A. Limit caffeine intake. While caffeine can affect some patients, it is not a specific concern with inhaled corticosteroids like beclomethasone.
B. Take the medication with meals. Inhaled corticosteroids like beclomethasone are typically not taken with meals as they are inhaled, not ingested.
C. Check the pulse after medication administration. Monitoring the pulse is not necessary for beclomethasone unless the client experiences specific symptoms related to tachycardia, which is not common with inhaled corticosteroids.
D. Rinse the mouth after administration. Rinsing the mouth after using inhaled corticosteroids helps prevent oral thrush and other oral side effects associated with the medication.
Correct Answer is A
Explanation
A. Daily or weekly weight: Daily or weekly weight measurements are a reliable way to assess fluid retention. A sudden increase in weight can indicate fluid overload.
B. Sodium level: While sodium levels can provide some information about fluid balance, they are not as direct or reliable as weight measurements for assessing fluid retention.
C. Tissue turgor: Tissue turgor can give some insight into hydration status but is subjective and less reliable compared to weight measurements, especially in clients with chronic conditions.
D. Intake and output: While monitoring intake and output is important for assessing fluid balance, it may not accurately reflect fluid retention, as it doesn't account for fluid shifts or loss through other routes.