A patient, age 54, is on postoperative day 2 after undergoing an open cholecystectomy. Immediately after the surgery, she vomited and may have aspirated some emesis. The nurse is concerned that the patient will develop pneumonia
In planning for her care, the nurse suspects the patient may have a. bacterial pneumonia.
b. aspiration pneumonia.
c. viral pneumonia.
d. atypical pneumonia.
B
Aspiration pneumonia occurs most commonly as a result of aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure, drugs, alcohol, anesthesia, acute infection, or shock.
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The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which:
a. toughens the cell wall. b. generates more T cells. c. attracts phagocytes. d. makes the antigen resistant.
With regard to the environment, it is important for the nurse to be aware of lighting for some clients. Clients with a diagnosis of schizophrenia may be bothered by lights that are flickering because this may trigger:
a. Overstimulation b. Hallucinations c. Aggressive behaviors d. Photophobia
The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semicomatose state?
A) A score of 20 B) A score of 15 C) A score of 9 D) A score of 4
The nurse is concerned about the fracture across the epiphyseal plate of a 9-year-old child because such a fracture could:
a. Interfere with bone growth b. Progress into osteomyelitis c. Cause a mis-union of the bone ends d. Lead to a long recovery period