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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Amitriptyline is a tricyclic antidepressant that is often used in low doses to treat neuropathic pain, including diabetic neuropathy. It can help relieve burning, shooting, or stabbing pain often associated with this condition.
A. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for relieving pain and inflammation associated with conditions like arthritis and musculoskeletal injuries. However, it is not typically used as a first-line treatment for neuropathic pain.
C. Celecoxib is a selective COX-2 inhibitor NSAID primarily used for its anti-inflammatory properties and pain relief in conditions like arthritis. While it may help with inflammation-associated pain, it is not specifically indicated for neuropathic pain.
D. While it may provide some relief, opioids are generally not recommended as first-line treatment for neuropathic pain due to their potential for dependence, tolerance, and other side effects.
Correct Answer is B
Explanation
B. Repositioning the client regularly is an important intervention to prevent pressure ulcers and pressure points, especially when the client is immobilized in traction. Repositioning helps distribute pressure evenly on different areas of the body, reducing the risk of tissue ischemia and pressure-related injuries around the edges of the splint.
A. Lotions or moisturizers can increase the risk of skin breakdown and infection, especially when applied under medical devices such as splints or casts.
C. Removing the weights for a few minutes each hour is not necessary to prevent pressure points around the edges of the splint. Balanced skeletal traction is typically applied to maintain continuous traction force on the fractured femur for therapeutic purposes.
D. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint. Foot plates are typically used to prevent foot drop and maintain proper alignment of the foot and ankle joints.
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