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. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.

A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.

C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.

D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.

A. The bone is cracked lengthwise but did not break all the way through. B. Fragments of bone have splintered into the surrounding tissue. C. The bone ends have been forced toward each other. D. Sharp edge of the bone has broken through the skin.

Correct Answer is A

Explanation

This description accurately reflects a greenstick fracture. In a greenstick fracture, the bone is partially fractured, typically on one side, while the other side remains intact. It is often compared to the way a green stick bends but does not break completely.

This description is more characteristic of a comminuted fracture, where the bone breaks into multiple fragments that may displace or splinter into the surrounding tissue.

This description is indicative of an impacted fracture, where the bone ends are driven into each other, often due to a compressive force.

This description is characteristic of an open or compound fracture, where the broken bone penetrates the skin and is exposed to the external environment.

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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 has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that which of the following injuries has occurred with a greenstick fracture?

Correct Answer is A

Explanation

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

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A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

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