A client has 200 ml bright bloody chest drainage following post ICD within 2 hours. Which of the following actions should the nurse take first?

1. A

   Increase the IV fluid flow rate

2. B

   Administer oxygen at 5 L/minute

3. C

   Elevate the head of the bed

4. D

   Inform to the physician about amount of the drainage

Appeared in: SGPGI Nursing Officer-2023

Explanation

• The patient's drainage rate is 100 mL/hour (200 mL in 2 hours).
• Drainage of bright red blood at a rate greater than 100 mL/hour is a classic sign of active postoperative hemorrhage.
• This is a life-threatening complication that the nurse cannot manage independently.
• The priority action is to immediately notify the physician or surgeon to allow for prompt diagnosis and intervention, which may include returning to the operating room.

Why Other Options Were Wrong

• Option A: Increasing IV fluids is a dependent action requiring a physician's order and does not address the source of the bleeding. The first step is to report the critical finding.
• Option B: Administering oxygen is a supportive measure. While important if the patient is hypoxic, it does not solve the primary problem of active bleeding.
• Option C: Elevating the head of the bed helps with lung expansion but has no direct effect on stopping a hemorrhage. It is not the priority in this emergency.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing actions for chest tube complications to guide bedside assessment, documentation, and the next nursing action.
• Nurses must perform diligent monitoring of chest tube output, including volume, color, and consistency, especially in the first few hours post-procedure.
• Recognizing and reporting drainage greater than 100 mL/hr is a critical patient safety responsibility to prevent progression to hypovolemic shock.
• What if? If the drainage was 40 mL over 2 hours and serosanguineous (pinkish), this would be a normal finding. The nurse's action would be to document the drainage and continue routine monitoring.

How to Approach the Question

• First, identify that this is a priority question by noting the word 'first'.
• Analyze the clinical data provided in the stem: 200 mL of 'bright bloody' drainage in 2 hours.
• Calculate the hourly rate: 200 mL / 2 hours = 100 mL/hour. Recognize that 'bright bloody' signifies active bleeding.
• Evaluate the significance of this finding. A drainage rate of 100 mL/hr of fresh blood is a critical, abnormal finding that indicates hemorrhage.
• Review the options based on urgency and the nurse's scope of practice. The most urgent need is to address the life-threatening bleeding.
• Determine the priority action. Reporting a critical finding to the physician for immediate medical or surgical intervention (an escalation action) takes precedence over supportive care (oxygen, positioning) or dependent actions that require an order (IV fluids).

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing actions for chest tube complications.
• Stem keywords: chest drainage, post ICD, 200 ml, bright bloody, 2 hours
• Lead-in keywords: first
• Clinical cues: The drainage amount (200 ml in 2 hours) and color (bright bloody) are critical cues indicating active hemorrhage.

Question ID

Qj3ySsC85oH90F4bFx4oQl

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 36-38, 35-37