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 A

Explanation

A. Preventing hip flexion of the affected extremity is often a key component of postoperative care following total hip arthroplasty. This helps prevent dislocation of the new hip joint and promotes proper healing.

B. While some caution is necessary to prevent excessive movement that could strain the surgical site, complete avoidance of movement in the affected leg is not recommended.

C. Ensuring that the client's heels are touching the bed is not typically a specific intervention related to postoperative care following total hip arthroplasty.

D. Positioning the lower extremities so that they are touching is not typically a specific intervention related to postoperative care following total hip arthroplasty.

A. "You will need to remove all jewelry before the test." B. "You will need to fast for 12 hours before the test." C. "You will need to empty your bladder before the test." D. "You will need to lie flat for 4 hours following the test."

Correct Answer is A

Explanation

A. Metal objects, including jewelry, can interfere with the DXA scan and affect the quality of the images. Therefore, it is important for the client to remove all jewelry and metal objects before the test to ensure accurate results.

B. Fasting is not typically required for a dual-energy x-ray absorptiometry (DXA) scan. DXA scans are non- invasive and do not involve the administration of any substances that would necessitate fasting.

C. This instruction is not specifically required for a DXA scan. However, it is generally a good practice for clients to empty their bladder before any imaging test to ensure comfort during the procedure.

D. This instruction is not accurate for a DXA scan. DXA scans are typically quick procedures that do not require the client to lie flat for an extended period afterward. Clients can resume their normal activities immediately following the scan without any restrictions.

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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 planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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