A nurse is caring for a client who is 2 days postoperative following abdominal Surgery and requires enteral feedings. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at highest risk for developing dropdown and dropdown.
Explanation & Rationale
Rationale: Aspiration: The client has high gastric residual volumes (220 mL at 0800, 280 mL at 0900) while receiving enteral feedings via NG tube. Delayed gastric emptying increases the risk that stomach contents could reflux and enter the lungs, causing aspiration pneumonia. Continuous monitoring and potentially holding or adjusting feedings are indicated. Skin breakdown: The client is postoperative, has an NG tube, limited mobility, and is experiencing pain that may reduce movement. These factors, combined with urine output changes and potential incontinence, increase the risk for pressure ulcers and skin breakdown at pressure points. Other risks such as bleeding, hyperglycemia, and urinary retention are less immediate given the client’s current assessment and lab/vital signs.