A patient following radical mastectomy shifting to the ward from recovery room after one hour surgery who has a Romovac drain which is half filled with blood. What is the priority nursing intervention?

1. A

   Patient having hemorrhage

2. B

   Loss of more body fluids

3. C

   It is normal after a surgery

4. D

   Nurse should check records in recovery room

Appeared in: NORCET 5 mains

Explanation

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• The primary concern is identifying the life-threatening complication.
• A Romovac drain half-filled with blood (approximately 200-400 mL) within the first hour post-op is a classic sign of active hemorrhage.
• Recognizing the situation as a hemorrhage is the priority cognitive step that precedes and directs all other nursing actions.
• This finding is far outside the normal range for post-mastectomy drainage, which is typically less than 100 mL in the first few hours and gradually decreases.

Why Other Options Were Wrong

• Option B: While hemorrhage does involve the loss of body fluids, this option is too general and does not convey the urgency or specific nature of the problem. 'Hemorrhage' is a precise medical diagnosis indicating severe, active bleeding.
• Option C: This amount of blood loss in such a short time is highly abnormal and a medical emergency. Normal drainage is significantly less and changes in character from bloody to serosanguineous over time.
• Option D: While reviewing patient records is part of comprehensive nursing care, it is not the immediate priority when faced with signs of a life-threatening hemorrhage. The priority is to assess the patient and escalate care immediately.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Assessment of post-operative complications, specifically hemorrhage following a mastectomy in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Early recognition of post-operative hemorrhage is a critical nursing responsibility that can prevent progression to hypovolemic shock and death.
• Nurses must be able to differentiate between expected post-operative findings and signs of critical complications.
• Promptly notifying the surgical team with precise information (amount of drainage, time frame, vital signs) is essential for a timely and effective response.

How to Approach the Question

• First, identify the patient's clinical situation: The patient is in the immediate post-operative period (1 hour) after a major surgery (radical mastectomy).
• Next, analyze the key clinical finding presented: The Romovac drain is 'half filled with blood'.
• Interpret this finding in the context of expected outcomes. Recall or deduce that a surgical drain filling this rapidly with blood is not normal and indicates excessive bleeding.
• Evaluate the options based on priority. The options include interpretations of the event (A, B, C) and a nursing action (D).
• Determine the most critical and immediate concern. The most significant issue is the active hemorrhage itself. Therefore, identifying the problem as 'hemorrhage' is the highest priority.
• Select the option that most accurately and urgently describes the clinical situation, which is that the patient is having a hemorrhage.

Concept Tested & Keywords

• Concept Tested: Assessment of post-operative complications, specifically hemorrhage following a mastectomy.
• Stem keywords: radical mastectomy, Romovac drain, half filled with blood, one hour surgery, priority nursing intervention
• Lead-in keywords: priority
• Clinical cues: The timeframe of 'one hour' post-surgery is critical, indicating an acute and rapid event.
• Clinical cues: The description 'half filled with blood' signifies a large volume of blood loss, not just typical drainage.

Question ID

QAdnGADgVLq9Z0EPvi6RSw

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Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 pp. 55-57, 54-56

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 122-124