Question

The nurse is suctioning a new postop laryngectomy client and notices bright red blood streaks in the sputum. Which action is appropriate? ? A. Immediately stop suctioning and call the physician ? B. Flush saline through the tubing and call the physician ? C. Document the finding as normal ? D. Prepare the client to go back to surgery

Short answer

Answer: The most appropriate action for the nurse to take is to immediately stop suctioning and call the physician.

Step-by-step solution

Analyze the situation.

First, consider the medical scenario presented. The patient is a new postoperative laryngectomy client and the nurse notices bright red blood streaks in the sputum. The main concern here is the presence of bright red blood streaks, which may indicate a complication or problem that needs to be addressed.

Evaluate option A.

Option A states that the nurse should immediately stop suctioning and call the physician. It seems reasonable that the nurse should notify the physician of the blood streaks, as this may indicate a problem. Keep this option in mind while evaluating the other options.

Evaluate option B.

Option B suggests that the nurse should flush saline through the tubing and call the physician. Flushing saline through the tubing may help to clear any existing blood, but it does not address the underlying cause of the blood streaks. Additionally, this option still involves calling the physician, similar to option A.

Evaluate option C.

Option C states that the nurse should document the finding as normal. This option is not suitable, as blood streaks are not a normal finding in a new postoperative laryngectomy client, and it may indicate a problem that should be addressed immediately.

Evaluate option D.

Option D suggests that the nurse should prepare the client to go back to surgery. While it is possible that the client may eventually need surgical intervention, it is not the nurse's responsibility to make this determination. This option is not appropriate, as it does not involve communicating with the physician or addressing the immediate concern.

Choose the best option.

Based on the evaluation of each option, the most appropriate action for the nurse to take is to immediately stop suctioning and call the physician (option A). This response addresses the concern of the blood streaks and ensures that the physician is made aware of the situation so that proper medical intervention can be provided.