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 C
Explanation
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B. Clients are usually instructed to fast before treatments that involve anesthesia or sedation, such as photodynamic therapy. Eating a full breakfast is not typically recommended before this type of treatment.
C. After photodynamic therapy, clients become extremely sensitive to light, including sunlight. Exposure to sunlight or strong indoor lights can cause skin damage, so clients are advised to avoid sun exposure for at least 6 weeks.
D. Skin markings made for treatment guidance should be preserved between treatments, but this is less critical in photodynamic therapy compared to radiation therapy, where precise location is essential for targeting tumors.
Correct Answer is C
Explanation
A. Informing the patient about possible tingling is not as reassuring and does not directly address their concern about spinal cord damage.
B. While paresthesia can occur, focusing on temporary effects might not alleviate the patient’s primary concern about spinal cord injury.
C. Explaining that the needle is placed below where the spinal cord ends directly addresses the patient’s anxiety about potential damage, providing clarity and reassurance about the safety of the procedure.
D. While it is important for patients to report numbness, this response does not reassure them about the procedure's safety and may increase their anxiety.