Question

The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response?

A) Assess the patient for signs of bleeding and inform the physician.
B) Monitor the patients vital signs every 15 minutes for the next hour.
C) Reposition the patient and reassess vital signs.
D) Palpate the patients flanks for pain and inform the physician.

Answer 1

The nurse's best response would be to assess the patient for signs of bleeding and inform the physician.

Step-by-step explanation:

The nurse's best response in this situation would be to assess the patient for signs of bleeding and inform the physician. The significant drop in level of consciousness and blood pressure, as well as the scant urine output, could indicate a potentially serious complication such as internal bleeding.

Assessing the patient for signs of bleeding can involve checking for any visible bleeding, monitoring vital signs for any signs of continued blood loss, and palpating the patient's flanks for pain or tenderness, as this could be an indicator of internal bleeding from the nephrectomy site.

Informing the physician is important because they will need to evaluate the patient's condition and determine the appropriate course of action, which may include ordering tests or procedures to address the potential bleeding.