A nurse is caring for a client who reports that she has insomnia.

Which of the following interventions is appropriate for the nurse to recommend?

Leaving the drain until the end of the shift is not appropriate because it could lead to complications such as:

• Hematoma formation:Blood accumulation in the tissues surrounding the drain can put pressure on surrounding structures,potentially impairing blood flow and causing tissue damage.
• Infection:A reservoir containing blood provides a favorable environment for bacterial growth,increasing the risk of infection.
• Drain occlusion:Clotted blood can block the drain,preventing effective drainage and leading to fluid buildup and potential infection.
• Decreased wound healing:Excessive blood loss can delay wound healing by depriving the tissues of necessary oxygen and nutrients.

Removing the drain without the surgeon's order is not appropriate because:

• Premature removal:It could disrupt the healing process and lead to complications such as fluid collection or infection.
• Assessment limitation:Removing the drain would eliminate the ability to monitor ongoing blood loss and could mask potential complications.

A Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied¹. The bulb should be emptied before it is more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing and to maintain the suction

Notifying the surgeon about the blood loss is wrong because it is not an urgent situation unless there are signs of excessive bleeding, such as bright red blood, clots, or a sudden increase in the amount of drainage²³. The surgeon should be notified if the drainage is more than 100 ml in 24 hours or if the color changes from serosanguineous (pink) to sanguineous (red)

Notify the healthcare provider.
The nurse should first notify the healthcare provider of the error in administering the IV bolus.
This is important because the healthcare provider can assess the situation and provide guidance on how to proceed.
Choice A is not the correct answer because obtaining the client’s vital signs is important but not the first action the nurse should take.
Choice C is not the correct answer because documenting the incident in the client’s medical record is important but not the first action the nurse should take.
Choice D is not the correct answer because assessing the client for adverse reactions is important but not the first action the nurse should take.