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. Difficulty or inability to abduct (raise out to the side) the arm at the shoulder is a classic finding in rotator cuff injuries, particularly in cases of significant tears or severe inflammation. This limitation in shoulder movement can be due to pain, weakness, or mechanical impingement caused by the injured rotator cuff.
A. The drop arm test is a physical examination maneuver used to assess for rotator cuff tears. In a negative drop arm test, the patient is able to slowly lower their arm from an abducted position (out to the side) to their side without significant pain or weakness. A negative test suggests that there may not be a complete tear of the rotator cuff.
B. Alteration in the contour of the shoulder joint could indicate various shoulder pathologies, including rotator cuff injuries. However, it is a nonspecific finding and can occur with other shoulder conditions as well.
C. Tinel's sign is a test used to assess for nerve compression or irritation. While it can be positive in conditions such as carpal tunnel syndrome, it is not typically associated with rotator cuff injuries.
Correct Answer is D
Explanation
D. Benzodiazepines are a class of medications commonly used to treat anxiety, insomnia, seizures, and muscle spasms. Mazepam is a benzodiazepine medication often prescribed for anxiety disorders and short-term relief of anxiety symptoms.
A. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, reduce inflammation, and lower fever.
B. Morphine is an opioid analgesic used to treat moderate to severe pain.
C. Acetaminophen is a pain reliever and fever reducer that is not classified as a benzodiazepine.
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