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 A

Explanation

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

A. The bone is cracked lengthwise but did not break all the way through. B. Fragments of bone have splintered into the surrounding tissue. C. The bone ends have been forced toward each other. D. Sharp edge of the bone has broken through the skin.

Correct Answer is A

Explanation

This description accurately reflects a greenstick fracture. In a greenstick fracture, the bone is partially fractured, typically on one side, while the other side remains intact. It is often compared to the way a green stick bends but does not break completely.

This description is more characteristic of a comminuted fracture, where the bone breaks into multiple fragments that may displace or splinter into the surrounding tissue.

This description is indicative of an impacted fracture, where the bone ends are driven into each other, often due to a compressive force.

This description is characteristic of an open or compound fracture, where the broken bone penetrates the skin and is exposed to the external environment.

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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?

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Naxlex Comprehensive Predictor Exams

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Correct Answer is A

Explanation

A nurse in an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that which of the following injuries has occurred with a greenstick fracture?

Correct Answer is A

Explanation

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