During data collection for a patient after cardiac surgery, the nurse notes that chest tube drainage has increased and is now greater than 200 mL per hour. What should the nurse do?
a. Notify registered nurse (RN).
b. Monitor oxygen saturation.
c. Recheck vital signs in 30 minutes.
d. Recheck drainage every 30 minutes.
ANS: A
The RN should be notified immediately so that the physician can be contacted. The patient needs immediate intervention to control possible hemorrhaging. B. Monitoring oxygen saturation can occur after the RN is notified. C. The vital signs should be assessed more frequently than every 30 minutes in this patient. D. The patient needs immediate attention. Waiting for 30 minutes to recheck the amount of drainage is inappropriate.
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