A client undergoes a gastroduodenostomy for treatment of a perforated ulcer. Postoperatively, the nurse cannot detect bowel sounds, and there is 200 mL of bright red blood in theNG drainage container. What is the most appropriate nursing action?
1. Notify the physician.
2. Irrigate the NG tube.
3. Apply an abdominal binder.
4. Assess the client's pain level.
Answer: 1
1. The findings indicate a rupture or bleed of the suture line, necessitating immediate intervention.
2. Irrigating the NG could cause further damage.
3. Applying a binder could cause further damage.
4. Assessment of pain level would be a subsequent intervention after notifying the physician.
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