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. Using a soft toothbrush is appropriate for preventing bleeding, but it does not directly indicate an understanding of neutropenia or its implications for infection risk.
B. Babysitting a young child may expose the client to infections, which is not safe for someone with neutropenia. This statement shows a lack of understanding.
C. Calling the oncologist when experiencing an increased temperature is critical because it may indicate an infection, which is a major concern for clients with neutropenia. This statement reflects an appropriate understanding of the condition.
D. While wearing a mask can be beneficial in some situations, stating that it must be worn at all times is not necessary and shows a misunderstanding of the guidelines for reducing infection risk in neutropenia.
Correct Answer is D
Explanation
A. A large cluster of pustules may indicate an infection or inflammatory process, but it is not necessarily indicative of an immediate danger compared to other options.
B. Raised, tubular, white areas may represent benign conditions, such as skin tags or cysts, which generally do not require urgent evaluation unless symptomatic.
C. Beige, small brown spots are often benign, such as liver spots or freckles; these typically do not signal immediate concern unless there are changes in size or color.
D. An irregular shaped, blue mole with white specks raises significant concern for potential melanoma, a serious form of skin cancer; any atypical characteristics in moles warrant immediate evaluation to rule out malignancy.