A client is 12 hours postoperative after abdominal surgery. For each finding or nursing response, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
New hypoxemia, increased work of breathing, acute distress, or a major change in breath sounds requires prompt respiratory assessment and escalation. Deep breathing, supported coughing, adequate analgesia with sedation reassessment, repositioning, and mobility as tolerated support ventilation and lung expansion. An isolated early postoperative low-grade fever is not sufficient evidence that atelectasis is the cause, and strict bed rest worsens pulmonary risk. The nurse evaluates the complete clinical picture and does not delay assessment of other causes.
Correct Answer Escalate new hypoxemia, increased work of breathing, or sudden unilateral loss of breath sounds. Use supported breathing and coughing, safe pain management, repositioning, and mobility to support expansion. Revise any plan that treats fever alone as proof of atelectasis or keeps the client on strict bed rest.
Why It Fits Priority follows present oxygenation and ventilation cues. Pulmonary care should improve participation while the nurse reassesses respiratory status, pain, and sedation.
Clinical Picture A fall in oxygen saturation with dyspnea is a current deterioration cue. Sudden unilateral absent sounds with distress can signal a serious complication and is not a routine finding. By contrast, a low-grade fever without respiratory change does not identify one pulmonary diagnosis.
Memory Link Assess oxygenation, support expansion, avoid fever shortcuts.
NCLEX Rule Choose the response based on the strongest current cue and risk of deterioration, not a fixed postoperative-day mnemonic or a single nonspecific finding.
Why the Alternatives Fail Strict bed rest promotes stasis and shallow ventilation. Attributing fever to atelectasis without assessing the client can miss infection, inflammatory response, aspiration, or another complication.
Source
1Mavros et al.: Atelectasis as a Cause of Postoperative Fever
22026 NCLEX-RN Test Plan
The client's preoperative oxygen saturation was 96% on room air. The nurse evaluates current respiratory cues, the effect of pain and sedation, and safe pulmonary-expansion measures without assuming that an isolated early fever proves atelectasis.
Postoperative Hypoxemia — A clinically important reduction in oxygenation after surgery. New desaturation, dyspnea, increased work of breathing, or mental-status change requires prompt assessment of ventilation, airway, sedation, and possible complications.
Pulmonary Expansion — Measures such as coached deep breathing, supported coughing, repositioning, adequate pain control, and mobility as tolerated that improve ventilation and reduce postoperative pulmonary stasis.
Early Postoperative Fever — A nonspecific finding that can reflect the inflammatory response to surgery or another process. Fever alone does not establish atelectasis as the cause and must be interpreted with the full clinical picture.