A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

75 mL of greenish-yellow drainage

150 mL of serosanguineous drainage

100 mL of red drainage

200 mL of brown drainage

Answer and Explanation

The Correct Answer is C

Choice A reason:

75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.

Choice B reason:

150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.

Choice C reason:

100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.

Choice D reason:

200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.

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Correct Answer is B

Explanation

Choice A reason:

"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.

Choice B reason:

“will have to wait 2 months before additional saline can be added to my breast expander" This is the correct statement. Following a modified radical mastectomy with a breast expander, additional saline is often added gradually to the expander to stretch the skin and muscle for reconstruction. The waiting period between saline additions allows for healing and proper tissue expansion. This statement indicates that the client understands the postoperative care and timeline.

Choice C reason:

"should expect less than 25 ml of secretions per day in the drainage devices": This statement is not accurate because the drainage amount can vary, and 25 ml per day might not be an accurate estimate.

Choice D reason:

"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.

A. Wound tissue firm to palpation B. Dry brown eschar C. Dark red granulation D. Light yellow exudate

Correct Answer is C

Explanation

Choice A reason:

Wound tissue firm to palpation is a false expectation. While firmness can be an indicator of healing in some wounds, it's not a reliable indicator on its own. The appearance and characteristics of the tissue, including granulation tissue, are more significant indicators of healing.

Choice B reason:

Dry brown eschar is a false expectation. Brown eschar is often necrotic tissue that needs to be removed for the wound to heal. Its presence typically suggests a lack of healing progress.

Choice C reason:

Dark red granulation tissue is the correct expectation because it is a sign of healing in a pressure ulcer. Granulation tissue is the new tissue that forms during the healing process, and the dark red color indicates that the tissue is well-vascularized and receiving adequate blood supply, which is essential for healing.

Dark red granulation tissue is a positive sign of wound healing. It indicates that new blood vessels are forming and that the wound is progressing toward the later stages of healing. Granulation tissue is crucial for wound repair and serves as the foundation for new tissue growth.

Choice D reason:

Light yellow exudate is a false expectation. Light yellow exudate is often indicative of infection or non-healing wounds. While some exudate is normal in the healing process, its colour alone doesn't necessarily indicate healing.

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A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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