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 ["A"]
Explanation
A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.
B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.
C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.
D. A client with postoperative delirium is not necessarily at risk of delirium.
E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores
Correct Answer is ["A","B","C","E"]
Explanation
A. Administering medication at the right time helps maintain therapeutic drug levels in the patient's system and ensures optimal treatment outcomes.
B. This means administering the correct medication to the patient as prescribed by the healthcare provider. It's crucial to verify the medication name, strength, and dosage form to prevent medication errors and adverse drug reactions.
C. It's essential to double-check the dose calculation and verify it against the prescription to prevent medication errors, especially with high-risk medications.
E. This means administering the medication to the correct patient. It's essential to verify the patient's identity using at least two patient identifiers (such as name and date of birth) before administering any medication to ensure it is being given to the intended recipient.
D. The color of medication is not typically considered one of the medication rights. While certain medications may have specific color coding for identification purposes, relying solely on color to identify a medication can be misleading and increase the risk of errors.
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