The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?
Tympanic temperature 99.2° F (37.3° C)
Fine crackles audible at both lung bases
200 mL sanguineous fluid in the wound drain
Redness and swelling along the suture line
The Correct Answer is C
C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock
A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).
B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.
D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.
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Related Questions
Correct Answer is D
Explanation
D. Excessive thyroid hormone replacement therapy, leading to hyperthyroidism, can accelerate bone turnover and increase the risk of osteoporosis. Hyperthyroidism can disrupt normal bone remodeling processes, leading to decreased bone mineral density and increased fracture risk.
A. NSAIDs are commonly used to reduce inflammation and relieve pain. While short-term or occasional use of NSAIDs is generally safe, long-term use or high doses of NSAIDs may be associated with an increased risk of osteoporosis and bone fractures.
B. Anticoagulants, such as warfarin and heparin, are medications used to prevent blood clot formation. While anticoagulants themselves are not directly associated with osteoporosis risk, prolonged immobilization due to conditions requiring anticoagulation therapy (such as deep vein thrombosis or pulmonary embolism) can increase the risk of osteoporosis and bone loss due to decreased weight- bearing activity.
C. Cardiac glycosides, such as digoxin, are medications used to treat heart failure and certain cardiac arrhythmias. There is no direct evidence to suggest that cardiac glycosides themselves are a risk factor for osteoporosis.
Correct Answer is C
Explanation
C. Erythrocyte sedimentation rate (ESR) is a blood test that measures the rate at which red blood cells settle in a tube of blood over time. ESR levels are commonly elevated in inflammatory conditions such as RA.
A. Rheumatoid factor (RF) is an autoantibody commonly found in individuals with rheumatoid arthritis (RA). However, monitoring RF levels is not typically used to evaluate the effectiveness of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) in managing RA symptoms.
B. ANA levels are not typically monitored to evaluate the effectiveness of aspirin or NSAIDs in managing RA symptoms.
D. Monitoring WBC count is important for assessing overall health and detecting infections but it is not specific to evaluating the effectiveness of aspirin or NSAIDs in managing RA symptoms.
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