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

Answer and Explanation

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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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.

A. Muscle spasms B. Hip pallor C. Leg abduction D. Leg lengthening

Correct Answer is A

Explanation

A. Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B. Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C. Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer is C

Explanation

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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