Question

"The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate?

a. Notify the physician
b. Continue to monitor the drainage
c. Document the finding
d. Mark the drainage on the dressing and monitor for any increase in bleeding."

Answer 1

The appropriate nursing action when noting bright red blood drainage on the dressing post-enucleation is to notify the physician immediately and marks the drainage to monitor any increase while documenting the findings.

Step-by-step explanation:

Clinical Focus: Nursing Action for Patient Following Enucleation

When a nurse notes the presence of bright red blood drainage on the dressing after a patient has undergone an enucleation, it is important to take appropriate actions. In this case, the most suitable action would be to notify the physician immediately. Bright red blood indicates fresh bleeding, which could signal a complication or excessive bleeding post-surgery. It is crucial for a healthcare professional to assess the situation to prevent any further complications. While the nurse should also mark the drainage on the dressing to monitor any increase in bleeding, the immediate priority is to bring this to the physician's attention. The nurse should document the finding thoroughly after the physician has been notified and any further instructions have been received.