The recovery room nurse has just received a patient whose abdominal drain has an excessive amount of sanguineous drainage. The nurse contacts the physician without delay, recognizing that the drainage could indicate which critical situation?
1. A major wound infection
2. Need for further assessment
3. A potential respiratory crisis
4. Need to return immediately to surgery
4
Rationale 1: A wound infection would not develop so rapidly.
Rationale 2: Further assessment is probably necessary, but this is not the nurse's major concern.
Rationale 3: Wound drainage is not indicative of an imminent respiratory crisis.
Rationale 4: An excessive amount of sanguineous drainage in the abdominal drain may require returning the patient to surgery so that the surgical site may be explored.
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