Question

while assessing a client who had a laparotomy the previous day, the nurse notices that 300 ml of dark red fluid has drained from the nasogastric tube in the last hour. which action should the nurse take first

Answer 1

The nurse should take the following action first:

1. Assess the client's vital signs: The nurse should check the client's blood pressure, heart rate, respiratory rate, and oxygen saturation levels. This will help determine if the client is experiencing any signs of hypovolemia or shock.

If the client's vital signs are stable, the nurse should proceed with the following actions:

2. Notify the healthcare provider: The nurse should inform the healthcare provider about the significant drainage of dark red fluid from the nasogastric tube. This could indicate bleeding or another serious complication that requires immediate attention.

3. Monitor the client's condition closely: The nurse should continue to assess the client's vital signs, level of consciousness, and overall condition. Any changes should be reported promptly to the healthcare provider.

4. Document the findings: Accurate and timely documentation is essential in providing comprehensive care. The nurse should record the amount, color, and consistency of the drainage, as well as the client's vital signs and any other relevant observations.

It is important for the nurse to prioritize the client's safety and well-being by promptly notifying the healthcare provider and closely monitoring the client's condition.