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?

200 mL of brown drainage

100 mL of red drainage

150 mL of serosanguineous drainage

75 mL of greenish-yellow drainage

Answer and Explanation

The Correct Answer is B

B. Red drainage from an NG tube can indicate fresh bleeding. While some blood in the immediate postoperative period may be expected, 100 mL is a significant amount for the first hour.

A Brown drainage from an NG tube in the immediate postoperative period can indicate the presence of old blood or bile. It is within a reasonable amount for the first hour postoperatively

C. Serosanguineous drainage is a mix of serum and blood, which can be normal in the early postoperative period.

D. Greenish-yellow drainage from an NG tube can indicate the presence of bile, which is also within the range of expected findings postoperatively.

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Correct Answer is A

Explanation

A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.

B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.

C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.

D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.

A. Furosemide B. Desmopressin C. Epinephrine D. Nitroprusside

Correct Answer is B

Explanation

B. Desmopressin is a synthetic analog of vasopressin (antidiuretic hormone) that promotes water reabsorption in the kidneys, reducing urine production. It is used to treat conditions associated with excessive urination, such as diabetes insipidus or nocturnal enuresis. Since the client is experiencing excessive thirst and polyuria (excessive urine output), desmopressin would be appropriate to help reduce urine volume and manage fluid balance.

A Given the client's already high urine output, administering furosemide would further increase urine production, potentially exacerbating fluid loss and dehydration.

C. Epinephrine does not address the underlying issue of excessive thirst and polyuria related to brain injury and would not be used in this context.

D. Nitroprusside is a vasodilator that reduces blood pressure by relaxing smooth muscle in blood vessels. It is used to treat hypertensive emergencies. Nitroprusside is not relevant for addressing excessive thirst and polyuria due to brain injury.

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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?

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