A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system
The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding?
A) Document the presence of normal bile output.
B) Irrigate the drainage system with normal saline as ordered.
C) Aspirate a sample of the drainage for culture.
D) Promptly report this assessment finding to the primary care provider.
Ans: A
Feedback:
Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
You might also like to view...
A 74-year-old woman has presented to the emergency department with a suspected hip fracture following a fall on the sidewalk outside her home
The nurse's assessment of the client would recognize which of the following factors as most likely contributed to the suspected injury? A) Bone remodeling in long bones ceases in the seventh or eighth decade. B) Bone minerals and mass are reduced as part of the aging process. C) Bone marrow production of cellular components declines with age. D) Thinning disks and shortened vertebrae are common assessment findings in older adults.
A client has just been admitted to your unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?
A) Are you experiencing fever, chills, or night sweats? B) Do you use artificial respirators? C) Have you ever had a blood transfusion? D) Have you ever experienced fractures?
Which will promote safety where oxygen is used?
a. Place a "NO SMOKING" sign in the room. b. Allow the person to smoke only outside when he is on oxygen. c. Allow the person to light scented candles. d. Ask the person's family members to limit how close they stand to the person if they are smoking.
Match each term to the correct definition below.
A. failure of lungs to expand B. dizziness C. excessive blood loss D. lack of oxygen E. period after surgery F. blood clot G. period before surgery