The nurse notes serosanguinous drainage from the nasogastric tube in the immediate postoperative period of a client who had a gastrectomy for gastric cancer. Which nursing action is appropriate?
Measure abdominal girth.
Continue to monitor the drainage.
Notify the physician.
Irrigate the nasogastric tube.
The Correct Answer is B
A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["16"]
Explanation
To calculate the volume to be withdrawn from the vial, we need to follow these steps:
- Convert the client's weight from pounds to kilograms:
- 110 lbs * (1 kg / 2.2 lbs) = 50 kg
- Calculate the total dose of Vancomycin based on the prescribed dosage:
- 20 mg/kg * 50 kg = 1000 mg
- Calculate the volume to be withdrawn from the vial:
- 1000 mg * (8 mL / 500 mg) = 16 mL
Correct Answer is C
Explanation
A. This statement indicates the client is aware of the importance of quitting smoking and is taking steps to do so, which is a positive action in managing their health after a lung cancer diagnosis.
B. Contacting the American Cancer Society shows the client and their family are seeking support, which is beneficial for coping with cancer, indicating good understanding of available resources.
C. Allowing others to smoke in the house poses significant health risks due to secondhand smoke exposure, which can aggravate the client's condition and hinder recovery. This indicates a lack of understanding regarding the dangers of smoking and the need for a smoke-free environment.
D. Spending quality time with family is a positive coping mechanism and reflects the client’s recognition of the importance of emotional support during their treatment journey.
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