The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy
The nurse's most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurse's best response?
A) Assess the patient for signs of bleeding and inform the physician.
B) Monitor the patient's vital signs every 15 minutes for the next hour.
C) Reposition the patient and reassess vital signs.
D) Palpate the patient's flanks for pain and inform the physician.
Ans: A
Feedback:
Bleeding may be suspected when the patient experiences fatigue and when urine output is less than 30 mL/h. The physician must be made aware of this finding promptly. Palpating the patient's flanks would cause intense pain that is of no benefit to assessment.
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