A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube
What action should the nurse take first?
a.
Document the findings in the chart.
b.
Notify the surgeon immediately.
c.
Reassess the drainage in 1 hour.
d.
Take a full set of vital signs.
ANS: D
The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an additional hour to reassess.
You might also like to view...
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response?
a. "Can you point to where it hurts?" b. "We'll talk more about that later in the interview." c. "What have you had to eat in the last 24 hours?" d. "Have you ever had any surgeries on your abdomen?"
A 23-year-old HIV-positive woman in the United States with routinely low viral loads and robust CD4+ cell counts is planning to get pregnant. Which precaution would her care giver eliminate from her care?
A) Offer her HAART that includes zidovudine B) Counsel her not to breast-feed C) Give her single-dose perinatal nevirapine D) Give the infant trimethoprim-sulfamethoxazole, starting at 4 to 6 weeks of age
The nurse, instructing a client on the prevention of osteoporosis, includes the importance of maintaining a normal serum calcium level because:
1. calcium influences the contraction of skeletal muscle. 2. calcium ions assist in blood clotting. 3. appropriate nerve conduction depends on an adequate calcium level. 4. the support provided by bones is important for the structural integrity of the body.
The nurse is instructing others on the use of hospice care. Which statements would indicate to the nurse that the teaching session has been effective? Select all that apply.
A. "Hospice care is designed for individuals with a terminal prognosis who decide to spend their final days at home with their families." B. "Hospice care is designed for individuals with a terminal prognosis who have to go into a hospice center for proper symptom management." C. "Hospice care is designed for individuals with a terminal prognosis who decide to stay in the hospital for symptom management." D. "Hospice care is designed for individuals with a terminal prognosis who decide to receive treatment for their symptoms at home, the hospital, or the hospice center." E. "Hospice care is designed for individuals with a terminal prognosis who cannot stay at the hospital."