A student nurse is caring for a young adult patient who is ...

[silviawilliams41]

A student nurse is caring for a young adult patient who is immobile with a back injury. On auscultation, the student nurse hears rhonchi in the lower lobes.
 
  The student nurse reports this symptom because the patient is developing which complication? a. Increased lung expansion
  b. Hypostatic pneumonia
  c. Aspiration pneumonia
  d. Increased diuresis

Question 2

The patient recently had a cast applied to his left lower leg after a football injury in which he broke his tibia. After the application of the cast, the nurse felt the toes of his left and right feet.
 
  To assess circulation in the left foot, the nurse should do which of the following? a. Use the tips of her fingers to assess temperature.
  b. Expect that the temperature in the left leg will be lower than that in the right.
  c. Expect that the temperature of the left foot to be the same as the right foot.
  d. Expect that the left foot will be warmer than the left.

[cat123]

Answer to Question 1

B
Decreased, not increased, lung expansion, generalized respiratory muscle weakness, and dependent stasis of secretions occur with immobility. These conditions often contribute to the development of atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Aspiration pneumonia results from aspiration, not from immobility. Diuresis is increased urine excretion.

Answer to Question 2

C
Compare symmetrical body parts, which should be the same in assessment. Always assess skin temperature for patients at risk for impaired circulation, such as after a cast application or vascular surgery. Normally the skin temperature is warm. Skin temperature is the same throughout the body. Accurately assess temperature by palpating the skin with the dorsum, or back, of the hand.