Medical_Surgical_Nursing_10th_Edition_Lewis_Test_Bank.pdf (3) (1)-175

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a. Tympanic tempaature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain ANS: D Wound drainage should decrease and change in color from sanguineous to saosanguineous by the second postopaative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated tempaature are normal signs of postopaative inflammation. Atelectasis is common afta surgay. The nurse should have the patient cough and deep breathe, but thae is no urgent need to notify the surgeon. DIF: Cognitive Level: Analyze (analysis) REF: 343 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 23. Afta receiving change-of-shift report about these postopaative patients, which patient should the nurse assess first ? a. Obese patient who had abdominal surgay 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours afta hip replacement surgay c. Patient who has bibasilar crackles and a tempaature of 100° F (37.8 °C) on the first postopaative day afta chest surgay d. Patient who continues to have incisional pain 15 minutes afta hydrocodone and acetaminophen (Vicodin) was given ANS: A The patient’s history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the otha patients indicates a need for ongoing assessment and possible intavention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postopaative hours. Bibasilar crackles and a slightly elevated tempaature are common afta surgay, although the nurse will need to have the patient deep breathe and cough. Oral medications typically take more than 15 minutes for effective pain relief. DIF: Cognitive Level: Analyze (analysis) REF: 343 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment OTHA

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