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 ["B","C","D"]
Explanation
B. Minimal edema (swelling) around the pin insertion site is an expected finding in clients with skeletal traction. Some degree of swelling may occur due to tissue trauma and the presence of foreign objects (such as the traction pins) within the soft tissues.
C. Slight pain or discomfort at the pin insertion site is common in clients with skeletal traction. The presence of traction pins can cause irritation or discomfort, especially during movement or weight- bearing activities.
A. Elastic bandages are not typically used to secure traction ropes in skeletal traction. Traction is usually maintained using specialized devices or weights attached to the traction ropes.
D.A small amount of clear, watery drainage is normal. This is the body's natural response to injury.
E. Movement of the pin at the insertion site is not an expected finding and may indicate inadequate stabilization or loosening of the pin. The pins should be securely anchored to the bone to maintain proper traction and stability.
Correct Answer is D
Explanation
D. Cyclosporine is typically taken on an empty stomach, either 1 hour before or 2 hours after a meal, to improve absorption. Taking it with food, especially high-fat meals, can decrease absorption and effectiveness.
A. Grapefruit juice can interact with cyclosporine, leading to increased blood levels of the medication and potentially causing toxicity. Therefore, clients should be advised to avoid grapefruit juice when taking cyclosporine.
B. Mixing cyclosporine oral solution with chocolate milk or any other liquid should be done only if directed by the healthcare provider or as specified in the medication instructions.
C. Using a plastic container to mix the oral solution may reduce the risk of interaction compared to using metal or glass containers. However, it's important to follow the specific instructions provided with the medication.
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