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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.

Choice B reason:

Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.

Choice C reason:

Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.

Choice D reason:

Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.

A. “use my heating pad on a low setting to keep my feet warm" B. ”rest in my recliner with my feet elevated for about an hour every afternoon” C. “soak my feet in hot water before trimming my toenails” D. “apply a lubricating lotion to the cracked areas on the soles of my feet every morning”

Correct Answer is D

Explanation

Choice A reason:

"use my heating pad on a low setting to keep my feet warm". This statement is incorrect. Using a heating pad, especially on a low setting, is not recommended for individuals with PAD. It can lead to burns or skin damage due to reduced sensation in the feet.

Choice B reason:

"rest in my recliner with my feet elevated for about an hour every afternoon" This statement is incorrect. While elevating the feet can help with blood circulation, it's important to avoid prolonged periods of inactivity. Regular physical activity is important for improving circulation.

Choice C reason:

"soak my feet in hot water before trimming my toenails". This statement is incorrect. Soaking feet in hot water can cause burns or damage to the skin for individuals with reduced sensation due to PAD. Trimming toenails should be done carefully and without soaking to prevent injury and infection.

Choice D reason:

"apply a lubricating lotion to the cracked areas on the soles of my feet every morning “This statement is correct. Clients with peripheral arterial disease (PAD) are at risk of reduced blood circulation to the extremities, including the feet. Proper foot care is crucial to prevent complications such as non-healing wounds or infections. Applying a lubricating lotion to cracked areas can help keep the skin moisturized and prevent further complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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