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

Chest tube drainage greater than 200 mL per hour is considered excessive and indicative of postoperative hemorrhage.
Sanguineous (bright red) drainage confirms active bleeding.
Hemorrhage is a life-threatening complication after cardiac surgery that can lead to hypovolemic shock and death if not treated promptly.
The priority nursing action is to report this critical finding to the surgeon immediately for urgent intervention.
Delaying notification can have catastrophic consequences for the patient.

Option A: This finding is highly abnormal and indicates a life-threatening complication. Documenting it as normal would be a serious error in clinical judgment.
Option B: Diuretics are contraindicated. They would worsen hypovolemia and hypotension in a patient who is actively bleeding.
Option D: Clamping the chest tube is extremely dangerous as it would trap the draining blood in the chest, leading to cardiac tamponade, which compresses the heart and impairs its function.

Visual 1: Diagram - A chest drainage unit, labeling the collection chamber, water-seal chamber, and suction control chamber. This helps visualize where the 300 mL of drainage would be measured.
Visual 2: Illustration - Cardiac tamponade, showing the accumulation of blood in the pericardial sac compressing the heart. This illustrates the danger of clamping the chest tube.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Management of post-operative complications following cardiac surgery, specifically assessing and responding to chest tube drainage in the correct sequence, documenting the action clearly, and monitoring for the expected response.
A nurse's primary role in post-cardiac surgery care is vigilant monitoring for complications like hemorrhage. Early detection and rapid communication are key to patient survival.
Recognizing critical thresholds for chest tube output (e.g., greater than 200 mL/hr) is a vital patient safety competency.
What if? If the chest tube drainage was 75 mL of serosanguineous fluid in the last hour, the priority action would be to document the finding as expected and continue to monitor the patient closely.

How to Approach the Question

First, identify the core clinical finding in the question: The patient has 300 mL of sanguineous chest tube drainage in one hour.
Next, analyze this finding. Ask yourself: 'Is this normal or abnormal for a patient two hours post-CABG?' Recall or determine that drainage over 150-200 mL/hr is a critical, abnormal finding.
Evaluate the options based on the abnormal finding. The problem is active bleeding (hemorrhage).
Option A (Document as normal) is incorrect because the finding is abnormal.
Option B (Diuretic) is incorrect because it treats fluid overload, not blood loss.
Option D (Clamp) is incorrect because it would cause a life-threatening cardiac tamponade.

Concept Tested & Keywords

Concept Tested: Management of post-operative complications following cardiac surgery, specifically assessing and responding to chest tube drainage.
Stem keywords: post-operative, Coronary Artery Bypass Graft (CABG), chest tube, drained 300 mL, sanguineous fluid, last hour
Lead-in keywords: priority action
Clinical cues: The drainage amount (300 mL) and character (sanguineous) are critical values indicating active bleeding.
Clinical cues: The time frame (in the last hour, two hours post-op) is significant as this is a high-risk period for hemorrhage.

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