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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A. A garden salad may contain raw vegetables, which can harbor bacteria and pose a risk of infection for a client with neutropenia, making this the concerning choice.
B. Applesauce is typically safe as it is a processed food that has been cooked, reducing the risk of bacterial contamination.
C. A baked potato is also safe as long as it is properly cooked and handled, which minimizes the risk of foodborne illness.
D. Steamed broccoli is safe because the cooking process eliminates harmful bacteria, making it a better choice for someone with neutropenia.
Correct Answer is A
Explanation
A. Reaction time is slower in older adults due to changes in the central nervous system and decreased neuronal processing speed, which can impact their overall response to stimuli.
B. Pain sensation is not typically heightened in older adults; rather, they may experience a decreased sensitivity to pain due to changes in the nervous system.
C. Higher basal body temperature is generally not associated with aging; older adults often have a lower baseline temperature.
D. While confusion can occur in older adults, it is not considered a normal age-related change and should be further evaluated for underlying causes rather than being expected.