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 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.

A. "Suction pressure that is too high causes this." B. "Your breathing pattern causes this." C. "This indicates a possible air leak." D. "This means your lung is fully re-expanded."

Correct Answer is B

Explanation

B. Changes in the fluid level of the water-seal chamber correspond to the client's breathing pattern. During inhalation, the negative pressure in the chest cavity may cause the fluid level to rise slightly as air is drawn into the tube, and during exhalation, the fluid level may fall as air exits through the chest tube.

A Fluctuations in the fluid level can occur due to changes in suction pressure settings, but this is more relevant to the suction control chamber rather than the water-seal chamber.

C. If there is continuous bubbling in the water-seal chamber, it indicates an air leak, which disrupts the normal function of the water-seal mechanism.

D. The water-seal chamber's fluctuation does not directly indicate lung re-expansion. Lung re-expansion is assessed through clinical examination, chest X-ray, or other diagnostic tests rather than the water-seal chamber.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

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