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 D

Explanation

D. Atorvastatin is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular events. Statins, including atorvastatin, have been associated with an increased risk of rhabdomyolysis, particularly when used in high doses or in combination with other medications that can interact to increase statin levels in the blood.

A. There is no direct evidence to suggest that omeprazole increases the risk of rhabdomyolysis when used in combination with colchicine.

B. There is limited evidence to suggest that hydrochlorothiazide significantly increases the risk of rhabdomyolysis when used in combination with colchicine.

C. There is no direct evidence to suggest that carvedilol increases the risk of rhabdomyolysis when used in combination with colchicine.

A. The ropes are securely attached to the pins. B. The weights are equal on each side. C. The weights rest against the foot of the bed. D. The ropes are in the center of the wheel grooves.

Correct Answer is C

Explanation

C. The weights in skeletal traction should not rest against the foot of the bed. Placing the weights on the floor or using a weight-bearing device such as a frame or stand is necessary to provide countertraction and maintain proper tension on the traction system.

A. In skeletal traction, the ropes or cables should be securely attached to the pins that are inserted into the bone. Proper attachment ensures that the traction force is applied effectively and safely.

B. In balanced skeletal traction, the weights on each side of the traction setup should be equal to maintain proper alignment and traction force. Balanced traction helps prevent unequal forces on the bone and surrounding tissues.

D. The ropes or cables should be properly positioned in the center of the wheel grooves to ensure smooth movement of the weights and prevent binding or friction. Proper alignment of the ropes reduces the risk of malfunction or damage to the traction equipment.

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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 reviewing the medication history of a client who has a new prescription for colchicine. Which of the following medications increases the client's risk when used in combination with colchicine for developing rhabdomyolysis?

Correct Answer is D

Explanation

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

Correct Answer is C

Explanation

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