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 B

Explanation

B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.

A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.

C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.

D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.

A. Venous thromboembolism B. Fluid and electrolyte imbalance C. Impaired surgical wound healing D. Hypovolemic shock

Correct Answer is A

Explanation

A. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant concern following knee replacement surgery due to the increased risk of blood clot formation associated with immobility and surgery. Limited mobility can predispose the patient to stasis of blood flow, which increases the risk of VTE.

B. While fluid and electrolyte imbalance can occur postoperatively, especially if the patient experiences complications such as excessive bleeding or fluid shifts, limited mobility alone is less likely to directly lead to this complication as a priority.

C. Limited mobility can potentially impact surgical wound healing by delaying the resolution of edema, impairing circulation, and increasing the risk of infection. However, this complication may not be as immediate or life-threatening as others on the list.

D. Hypovolemic shock, characterized by inadequate tissue perfusion due to decreased circulating blood volume, is a severe complication that can result from significant blood loss. While bleeding can occur postoperatively, it is less common as a complication of knee replacement surgery, especially within the first few days.

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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 caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?

Correct Answer is B

Explanation

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient?

Correct Answer is A

Explanation

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?

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A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

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