A client undergoes a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. Postoperatively the nurse cannot detect bowel sounds and there is 200 mL of bright red blood in the nasogastric (NG) drainage container
What is the most appropriate nursing action? A)
Assess the client's pain level.
B)
Irrigate the NG tube.
C)
Apply an abdominal binder.
D)
Notify the physician.
D
Explanation:
A)
The findings indicate a rupture or bleed of the suture line, necessitating immediate intervention. Assessment of pain level would be a subsequent intervention after notifying the physician. Irrigating the NG and applying a binder could cause further damage.
Analysis
Implementation
Physiological Integrity: Basic Care and Comfort
B)
The findings indicate a rupture or bleed of the suture line, necessitating immediate intervention. Assessment of pain level would be a subsequent intervention after notifying the physician. Irrigating the NG and applying a binder could cause further damage.
Analysis
Implementation
Physiological Integrity: Basic Care and Comfort
C)
The findings indicate a rupture or bleed of the suture line, necessitating immediate intervention. Assessment of pain level would be a subsequent intervention after notifying the physician. Irrigating the NG and applying a binder could cause further damage.
Analysis
Implementation
Physiological Integrity: Basic Care and Comfort
D)
The findings indicate a rupture or bleed of the suture line, necessitating immediate intervention. Assessment of pain level would be a subsequent intervention after notifying the physician. Irrigating the NG and applying a binder could cause further damage.
Analysis
Implementation
Physiological Integrity: Basic Care and Comfort
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