A patient recovering from cardiovascular surgery has a chest tube output of 110 mL/hr. What should the nurse do?
Select all that apply.
1. Report to the surgeon.
2. Check the hemoglobin and hematocrit.
3. Administer a blood transfusion.
4. Notify the family.
5. Strip and vent the chest tube.
Correct Answer: 1, 2
Chest tube drainage greater than 70 mL/h indicates hemorrhage and may necessitate a return to surgery. The surgeon should be notified of this chest tube draining amount. A drop in hemoglobin and hematocrit may indicate hemorrhage that is not otherwise obvious. The patient needs to be assessed along with the laboratory data before it is determined if a blood transfusion is necessary. There is no need to notify family until the patient has been assessed. It may not be of significance. Stripping and venting of the chest tube is not necessary because of the use of a closed drainage system.
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