A nurse is preparing to administer medication to a client. Which of the following should the nurse use as a client identifier?

Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL.

Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL.

Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL.

Therefore, the nurse should record the net fluid intake as 440 mL.

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)