The nurse notes serosanguinous drainage from the nasogastric tube in the immediate postoperative period of a client who had a gastrectomy for gastric cancer. Which nursing action is appropriate?

Measure abdominal girth.

Continue to monitor the drainage.

Notify the physician.

Irrigate the nasogastric tube.

Answer and Explanation

The Correct Answer is B

A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.

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Correct Answer is B

Explanation

A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.
B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.
C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.
D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.

A. Human papilloma virus (HPV) vaccination in teenagers B. BRCA1 and BRCA2 testing when the client's mother and sister died of ovarian cancer C. Annual mammogram for women over 40 years D. Rehabilitation exercises for those who received chemotherapy

Correct Answer is A

Explanation

A. The HPV vaccination is a form of primary prevention as it aims to prevent the initial occurrence of cervical cancer by protecting against the human papillomavirus, which is a major risk factor for this cancer.
B. BRCA1 and BRCA2 testing is a form of genetic testing used for risk assessment rather than prevention; it helps identify individuals at high risk for breast and ovarian cancers but does not prevent cancer itself.
C. Annual mammograms are a secondary prevention measure aimed at early detection of breast cancer rather than preventing the disease from occurring, as they help identify cancer in its early stages.
D. Rehabilitation exercises post-chemotherapy are supportive measures for patients undergoing treatment; they do not constitute primary prevention, which focuses on measures taken before cancer develops.

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The nurse notes serosanguinous drainage from the nasogastric tube in the immediate postoperative period of a client who had a gastrectomy for gastric cancer. Which nursing action is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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