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.
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Correct Answer is A
Explanation
A. Chewing food on the unaffected side helps to prevent triggering pain episodes in the affected side of the face, which is critical for managing trigeminal neuralgia effectively.
B. While maintaining oral hygiene is important, the timing of brushing teeth is less critical than managing pain during eating. Brushing teeth should be done gently to avoid pain but is not specifically prioritized over other interventions.
C. Avoiding an electric razor is not relevant to managing trigeminal neuralgia pain; it relates more to safety and comfort in shaving rather than pain management.
D. Food should not be served hot or cold as extreme temperatures can trigger pain in trigeminal neuralgia patients; it's better to serve food at a moderate temperature.
Correct Answer is B
Explanation
A. 1500: This is incorrect
B. The calculation is as follows:
Remaining fluid: 600 mL
IV rate: 100 mL/hour
Time to empty the bag: 600 mL ÷ 100 mL/hour = 6 hours
Adding 6 hours to the report time:
0700 + 0600 = 1300
The correct answer is 1300.
C. 1400: This is incorrect
D. 1500: This is incorrect