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?

200 mL of brown drainage

100 mL of red drainage

150 mL of serosanguineous drainage

75 mL of greenish-yellow drainage

Answer and Explanation

The Correct Answer is B

B. Red drainage from an NG tube can indicate fresh bleeding. While some blood in the immediate postoperative period may be expected, 100 mL is a significant amount for the first hour.

A Brown drainage from an NG tube in the immediate postoperative period can indicate the presence of old blood or bile. It is within a reasonable amount for the first hour postoperatively

C. Serosanguineous drainage is a mix of serum and blood, which can be normal in the early postoperative period.

D. Greenish-yellow drainage from an NG tube can indicate the presence of bile, which is also within the range of expected findings postoperatively.

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Correct Answer is B

Explanation

B. Photophobia, or sensitivity to light, is a common symptom in clients with meningitis. It occurs due to irritation of the meninges and the optic nerve by the inflammatory process. Clients may avoid bright lights and prefer dimly lit environments to reduce discomfort.

A Bradycardia (slow heart rate) is not typically associated with meningitis. In fact, many clients with meningitis may present with tachycardia (fast heart rate) due to fever, dehydration, and systemic inflammation. Therefore, bradycardia is not an expected finding in meningitis.

C. Petechiae (small red or purple spots) on the chest can occur in bacterial meningitis, particularly in cases caused by Neisseria meningitidis. These petechiae are often seen in clusters and can indicate disseminated intravascular coagulation (DIC), a serious complication associated with meningococcal infection. However, they are less specific

D. Headache is a hallmark symptom of meningitis, typically described as severe and persistent. It is often accompanied by other symptoms such as fever, neck stiffness (nuchal rigidity), photophobia, and altered mental status. Headache in meningitis is usually continuous rather than intermittent.

A. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack B. A client who has a headache following a grade 1 concussion C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash D. A client who has experienced brain death and is awaiting organ procurement

Correct Answer is C

Explanation

C. Clients with this score may have altered consciousness and require close monitoring for changes in neurological status, respiratory function, and other complications. Placing this client closest to the nurses' station allows for prompt assessment and intervention if there is deterioration or emergent need.

A Clients with a score of 0 are generally stable and may not require immediate or intensive monitoring. Therefore, this client may not need to be placed closest to the nurses' station unless there are other medical considerations.

B. A grade 1 concussion is considered mild, and while the client may have symptoms such as headache, they are typically stable with minimal risk of deterioration. Monitoring for worsening symptoms is important, but this client may not require immediate proximity to the nurses' station unless symptoms worsen unexpectedly.

D. Clients who are brain dead and awaiting organ procurement are typically stable in terms of neurological status as they are no longer responsive. This client may not necessarily need to be closest to the nurses' station unless specific care needs arise.

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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

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