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
A. The absence of bowel sounds shortly after surgery is a common finding and does not necessarily indicate a complication at this time; it is expected during the initial postoperative period.
B. An SPO2 of 90% while the client is asleep is concerning, but it does not take precedence over signs of possible surgical complications that could require immediate intervention.
C. Increasing abdominal distention is a critical sign that could indicate serious complications such as an anastomotic leak, bowel obstruction, or intra-abdominal bleeding, and it requires immediate notification of the surgeon for further evaluation and potential intervention.
D. A small amount of green-tinged fluid from the nasogastric tube is typical postoperatively and does not necessitate immediate notification to the surgeon unless the volume is excessive or other concerning signs are present.
Correct Answer is A
Explanation
A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.
B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.
C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.
D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.