The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
The 24-hour oral intake is 600 ml greater than the total output.
The patient's temperature is 100.3" F 137.9" C).
The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating
The patient's calf is swollen, warm, and painful.
The Correct Answer is D
These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.
DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Venous thromboembolism refers to the formation of blood clots in the veins, which can lead to serious complications such as pulmonary embolism. After surgery, immobility and reduced activity can increase the risk of developing blood clots. Therefore, it is crucial to prioritize measures to prevent venous thromboembolism, such as early mobilization, compression stockings, and anticoagulant medications, to ensure the patient's safety and well-being.
Correct Answer is C
Explanation
Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.
Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.
Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.
Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.
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