A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
75 mL of greenish-yellow drainage
150 mL of serosanguineous drainage
100 mL of red drainage
200 mL of brown drainage
The Correct Answer is C
Choice A reason:
75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.
Choice B reason:
150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.
Choice C reason:
100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D reason:
200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.
Choice B Reason:
Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.
Choice C Reason:
A chest physiotherapy (CPT) vest, also known as a high-frequency chest wall oscillation (HFCWO) vest, is commonly used by clients with cystic fibrosis to help clear mucus from the lungs. The vest vibrates at high frequency, loosening the mucus and making it easier for the client to cough it up, thus helping to manage respiratory symptoms and reduce the risk of infections.
Choice D Reason:
A peak flow meter is typically used for clients with asthma to measure the maximum speed of exhalation, which helps in assessing asthma control. While it can be useful for monitoring lung function, it is not specific to cystic fibrosis, where the primary concern is airway clearance rather than peak flow measurement.
Correct Answer is D
Explanation
Choice A Reason:
Applying lotion between the toes - Applying lotion between the toes can create a moist environment that may increase the risk of fungal infections. Lotion application should be done on the tops and bottoms of the feet, avoiding the spaces between the toes.
Choice B Reason:
Inspecting the feet every other day - Daily foot inspections are recommended for individuals with diabetes to identify any changes or abnormalities early and prevent potential complications.
Choice C Reason:
Soaking the feet twice a day - Excessive soaking of the feet can lead to maceration of the skin and increase the risk of infection, so it's generally not recommended. Regular washing with mild soap and water is sufficient for foot hygiene.
Choice D Reason
Trim toenails straight across When providing discharge teaching about foot care to a client with diabetes, the nurse should include information about proper foot care practices to prevent complications. Trimming toenails straight across is recommended to avoid ingrown toenails and potential injury. This reduces the risk of foot complications that can arise due to diabetes-related circulatory and neuropathic changes.
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