A patient who is recovering from cardiovascular surgery is demonstrating chest tube output of greater than 100 mL per hour
Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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. Connect pacemaker wires.
1,2
Rationale 1: It is abnormal to have greater than 100 mL of drainage in 1 hour. It may indicate bleeding and needs to be assessed by the surgeon.
Rationale 2: Hemoglobin and hematocrit should be checked.
Rationale 3: The patient needs to be assessed along with the laboratory data before it is determined if a blood transfusion is necessary.
Rationale 4: There is no need to notify the family until the patient has been assessed. The finding may be of no significance.
Rationale 5: An increase in chest tube drainage does not indicate the need for a pacemaker.
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