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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Explanation
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C. The CEA blood test is not routinely used for cancer screening; it is primarily used to monitor treatment response or recurrence, not for predicting the development of cancer.
D. Waiting until the age of 60 to be concerned about colon cancer is not advisable, especially with a family history; proactive discussions about screening should begin earlier based on risk factors.
Correct Answer is ["A","B","C"]
Explanation
A. An irregular border is a key characteristic of potentially cancerous skin lesions, particularly melanoma. Melanomas often have uneven, poorly defined edges.
B. Asymmetry is another sign of melanoma. If one half of a lesion does not match the other in shape or size, it should be evaluated by a healthcare professional.
C. Any lesion that has been increasing in size, particularly over a short period, is a concern and should be checked. Rapid growth can be a sign of malignancy.
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