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. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.
Correct Answer is C
Explanation
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.