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
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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Related Questions
Correct Answer is D
Explanation
D. Wearing goggles or eye protection when irrigating a wound helps prevent splashes or sprays of contaminated fluid from entering the nurse's eyes.
A Gowns are typically used during direct patient contact if there is an expectation of substantial contact with blood or body fluids.
B Sterile gloves are not typically required for administering an intramuscular (IM) injection. Instead, clean non-sterile gloves are sufficient to maintain aseptic technique during the procedure.
C. Recapping needles using both hands can increase the risk of needlestick injuries. It is recommended to use a one-handed scoop method or a safety device to recap needles safely.
Correct Answer is B
Explanation
A Clearing the area is essential to prevent injury during a seizure. The client may move or thrash around, and any objects nearby (e.g., furniture, medical equipment, or sharp objects) can potentially cause harm. However, this can be done after lowering teh client.
B. This action is crucial to protect the client from injury during the seizure. It provides a safe environment for the client to have the seizure without risk of falling or hitting their head on objects.
C. Assessing vital signs can wait until after the seizure has ended and the client's immediate safety has been ensured. During a seizure, the nurse should focus on managing the seizure and preventing complications.
D. This action is important for comfort and safety but is secondary to ensuring a safe environment and managing the seizure itself.
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