A patient is two hours post-operative from a Coronary Artery Bypass Graft (CABG) surgery. The nurse notes that the chest tube has drained 300 mL of sanguineous fluid in the last hour. What is the nurse's priority action?

Appeared in: NORCET 9 Prelims-2025

Explanation

The patient's chest tube drainage of 300 mL in one hour is a critical finding that signifies excessive bleeding or hemorrhage.
Standard nursing protocols for post-cardiac surgery indicate that drainage greater than 150-200 mL per hour is a sign of active hemorrhage and must be reported immediately.
Notifying the surgeon is the priority action to facilitate immediate intervention, which may include returning to the operating room to control the bleeding.
Delaying notification can lead to severe complications such as hypovolemic shock, cardiac tamponade, and death.

Option A: This amount of drainage is significantly higher than the normal expected output (less than 100-150 mL/hr) and indicates a life-threatening complication, not a normal finding.
Option B: Diuretics treat fluid volume excess, not blood loss (hypovolemia). Administering a diuretic would further deplete the patient's circulating volume, worsening shock.
Option D: Clamping the chest tube is contraindicated during active bleeding. It traps blood in the chest cavity, preventing its evacuation and leading to cardiac tamponade, which is a rapid and fatal compression of the heart.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Post-operative complications of Coronary Artery Bypass Graft (CABG) surgery, specifically chest tube management and recognition of hemorrhage in the correct sequence, documenting the action clearly, and monitoring for the expected response.
A nurse's primary role in immediate post-cardiac surgery care is vigilant monitoring for hemorrhage and tamponade. Prompt recognition and reporting of excessive chest tube drainage are life-saving interventions.
This scenario highlights a critical patient safety issue. Failure to act correctly (i.e., choosing to clamp the tube or document as normal) can have fatal consequences.
What if? If the drainage was 200 mL in the first hour, then suddenly dropped to 5 mL in the second hour, and the patient became hypotensive with muffled heart sounds, the nurse should suspect cardiac tamponade due to a clot obstructing the chest tube. This is also an emergency requiring immediate notification of the surgeon.

How to Approach the Question

First, identify the question type: It's a clinical scenario asking for a priority action.
Analyze the patient data provided: The patient is 2 hours post-CABG, a high-risk period. The key clinical finding is 300 mL of sanguineous chest tube drainage in one hour.
Recall or look up the normal and abnormal parameters for chest tube drainage post-cardiac surgery. Recognize that 300 mL/hr is far above the critical threshold of 150-200 mL/hr.
Evaluate each option based on the identified problem (hemorrhage) and nursing priorities (safety, ABCs).
Eliminate options that are incorrect or harmful. Documenting is passive, diuretics are for a different problem, and clamping is dangerous.
Select the option that directly addresses the life-threatening problem by escalating to the team member who can intervene surgically: notifying the surgeon.

Concept Tested & Keywords

Concept Tested: Post-operative complications of Coronary Artery Bypass Graft (CABG) surgery, specifically chest tube management and recognition of hemorrhage.
Stem keywords: Coronary Artery Bypass Graft (CABG), post-operative, chest tube, 300 mL, sanguineous fluid
Lead-in keywords: priority action
Clinical cues: The patient is two hours post-operative, a critical period for monitoring bleeding.
Clinical cues: The drainage is 300 mL in one hour, a specific and high value.

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 35-37

Practise the full NORCET 9 Prelims-2025

Attempt every question from this paper in a timed mock, then review the full solution for each one.