A Client Has Returned to the Nursing Unit After an Open

question 5

Multiple Choice

A client has returned to the nursing unit after an open Nissen fundoplication.The client has an indwelling urinary catheter,a nasogastric (NG) tube to low continuous suction,and two IVs.The nurse notes bright red blood in the NG tube.What action should the nurse take first?

• A) Document the findings in the chart.
• B) Notify the surgeon immediately.
• C) Reassess the drainage in 1 hour.
• D) Take a full set of vital signs.

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Definitions:

Circadian Rhythm

The natural, internal process that regulates the sleep-wake cycle and repeats roughly every 24 hours, influencing physical, mental, and behavioral changes.

Alpha Wave Pattern

A pattern of brain wave activity that symbolizes a state of wakeful rest, typically associated with relaxed and calm wakefulness.

Hypnagogic Sensation

Experiences or sensations, such as seeing or hearing things, that occur during the transition from wakefulness to sleep.

Consciousness

The state of being aware of and able to think and respond to one's surroundings and experiences.