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 C
Explanation
C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.
A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.
B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.
D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.
Correct Answer is A
Explanation
A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.
B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.
C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.
D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.
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