A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?
A.
Lethargy
B.
Bradycardia
C.
Intercostal retractions
D.
Bradypnea
The Correct answer and Explanation is:
The correct answer is C. Intercostal retractions.
Explanation:
Atelectasis is a condition characterized by the collapse or incomplete expansion of lung tissue, leading to impaired gas exchange and resulting in hypoxia. After surgery, patients may be at risk for atelectasis due to factors such as anesthesia, pain, and reduced mobility, which can contribute to shallow breathing and decreased lung expansion.
When assessing a client with postoperative atelectasis who is hypoxic, the nurse should look for specific clinical manifestations. Among the options provided, intercostal retractions are a significant indicator. Intercostal retractions occur when the muscles between the ribs pull inward during inhalation, which often signifies respiratory distress and indicates that the patient is struggling to breathe effectively. This effort to draw in air can be a response to low oxygen levels, as the body tries to increase the effort of ventilation to compensate for poor gas exchange.
In contrast, the other options—lethargy, bradycardia, and bradypnea—are not the primary manifestations associated with atelectasis. While lethargy can occur due to hypoxia, it is more of a general symptom rather than a specific indicator of atelectasis. Bradycardia (slow heart rate) can result from various factors, including vagal stimulation, but is not directly associated with the respiratory compromise caused by atelectasis. Bradypnea (slow breathing) might occur in some cases; however, patients with hypoxia and respiratory distress typically exhibit tachypnea (rapid breathing) as a compensatory mechanism.
In summary, intercostal retractions are a direct manifestation of the respiratory distress caused by atelectasis and are a critical sign for the nurse to assess, as they indicate that the patient is working harder to breathe in response to inadequate oxygenation.