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 B
Explanation
Choice A Reason:
Magnesium - While magnesium levels can affect cardiac function, hypomagnesemia is not a primary risk factor for digoxin toxicity.
Choice B Reason:
Potassium. An imbalance of potassium can increase the risk of digoxin toxicity. Hypokalaemia (low potassium levels) enhances the binding of digoxin to its target receptors in the heart, leading to an increased risk of digoxin toxicity. It's essential to monitor potassium levels in clients taking digoxin, as maintaining a stable potassium level helps prevent adverse effects associated with digoxin therapy.
Choice C Reason:
Phosphatase - Phosphate levels are not commonly associated with an increased risk of digoxin toxicity.
Choice D Reason:
Calcium - Calcium levels can affect cardiac function, but they are not a primary factor in the development of digoxin toxicity.
Correct Answer is C
Explanation
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.
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