A patient recovering from gastric surgery has red fluid in the nasogastric tube. Vital signs are temperature 98°F; heart rate 104; respirations 23; blood pressure 105/69. Which action by the nurse is indicated?
1. Document the findings and notify the healthcare provider.
2. Document the findings and reassess the patient in 4 hours.
3. Review the patient's most recent laboratory results.
4. Document the findings and review the nasogastric suction settings.
Correct Answer: 1
The patient's assessment is consistent with an early hemorrhage. The situation warrants contacting the healthcare provider. Reassessment of the patient in 4 hours would allow too much time to pass before reevaluation and may result in serious complications. The laboratory values might yield useful information but would be secondary to a consultation with the healthcare provider. The nasogastric suction settings can be reviewed, but the healthcare provider must still be notified.
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