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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Muscle twitching post-thyroidectomy can indicate hypocalcemia, a common complication due to inadvertent damage or removal of the parathyroid glands during surgery. Hypocalcemia can lead to neuromuscular irritability, including muscle twitching, tingling, or tetany.
A Nausea is a common postoperative symptom and can be caused by anesthesia, pain medications, or changes in gastrointestinal function. While uncomfortable, nausea alone is typically not an urgent concern
B Serosanguineous drainage (thin, pink-tinged fluid) from the surgical incision is expected in the early postoperative period. It indicates normal wound healing and does not usually require urgent attention
D. Routine incisional pain does not typically require urgent reporting unless accompanied by other concerning symptoms.
Correct Answer is C
Explanation
C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.
A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.
B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.
D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP
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