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 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.
Correct Answer is B
Explanation
B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.
A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.
C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.
D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.
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