Question

When turning the right-modified mastectomy client to her left side, the nurse notes a moderate amount of serosanguinous drainage on the bed sheets. Which nursing action is appropriate? ? A. Remove the dressing to ascertain the origin of the bleeding ? B. Milk the hemovac tubing using a continuous downward motion ? C. Note vital signs, reinforce the dressing, and notify the surgeon ? D. Recognize this is a frequent occurrence with this type of surgery

Short answer

A. Removing the dressing to determine the origin of the bleeding. B. Milking the hemovac tubing using a continuous downward motion. C. Noting vital signs, reinforcing the dressing, and notifying the surgeon. D. Recognizing that this is a frequent occurrence with this type of surgery. Answer: C. Noting vital signs, reinforcing the dressing, and notifying the surgeon.

Step-by-step solution

Analyzing the scenario

First, read and understand the given scenario. In this case, a nurse observes moderate serosanguinous drainage on the bed sheets when turning a mastectomy patient to her left side.

Evaluating Option A

Option A suggests removing the dressing to determine the origin of the bleeding. This could be considered a potential action to take, but it's not the most appropriate one, as it doesn't take into account the patient's overall condition or notifying the appropriate medical professionals.

Evaluating Option B

Option B suggests milking the hemovac tubing using a continuous downward motion. This action is to promote drainage and prevent clots in the tubing, but it may not be the most appropriate action in this case since it doesn't involve addressing the overall patient condition or notifying the surgeon.

Evaluating Option C

Option C suggests noting vital signs, reinforcing the dressing, and notifying the surgeon. This option seems to be the most appropriate since it involves monitoring the patient's condition, taking necessary measures to control the bleeding, and informing the surgeon, who would be responsible for determining if further action or intervention is needed.

Evaluating Option D

Option D suggests recognizing that this is a frequent occurrence with this type of surgery. Even if it were a frequent occurrence, it's crucial to monitor the patient's condition and inform the surgeon, making this option not the most appropriate.

Selecting the appropriate nursing action

Based on the evaluation of each option, Option C (Note vital signs, reinforce the dressing, and notify the surgeon) is the most appropriate nursing action in this scenario. It addresses the patient's condition and communicates with the appropriate healthcare professional if needed.