The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?
A) Remove the patient's drain and apply pressure with a sterile gauze.
B) Assess the patient, reposition the patient supine, and apply wall suction to the drain.
C) Rapidly assess the patient and notify the surgeon about the patient's bleeding.
D) Administer a STAT dose of vitamin K to aid coagulation.
Ans: C
Feedback:
The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be administered without an order.
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