Following lung resection surgery, the patient loses 350 ml of blood in the chest drainage system during the first hour post-op. The priority action for the nurse is to:
clamp the chest tube to avoid further blood loss.
monitor the chest tube drainage every 15 minutes for 1 hour.
contact the physician to report possible hemorrhage.
administer protamine to reverse the bleeding.
The Correct Answer is C
Rationale:
A. Clamping a chest tube after lung surgery is contraindicated because it can cause tension pneumothorax or accumulation of blood in the pleural space, worsening respiratory compromise.
B. While close monitoring is important, simply observing does not address the potential life-threatening complication. The amount of blood lost in a short period is concerning and requires immediate reporting and intervention.
C. Loss of 350 ml of blood in the first hour post-op is above expected post-surgical drainage and indicates possible hemorrhage. This is a priority finding because continued bleeding can lead to hypovolemic shock. Prompt communication with the physician is essential to initiate interventions such as fluid resuscitation, blood transfusion, or return to surgery if necessary.
D. Protamine is used to reverse heparin anticoagulation. There is no indication that the patient received heparin, and administering it without cause could be harmful. The priority is to report the hemorrhage and allow the physician to determine appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This is incorrect
B. This is incorrect
C. Step 1: Use the formula
Flow rate (mL/hr) = Total volume ÷ Time in hours
Step 2: Convert minutes to hours
30 minutes = 0.5 hour
Step 3: Insert known values
Total volume = 100 mL
Time = 0.5 hr
Flow rate = 100 ÷ 0.5
Flow rate = 200 mL/hr
Step 4: Match to the options
200 mL/hr
Final Answer: C. 200 mL/hr
D. This is incorrect
Correct Answer is D
Explanation
Rationale:
A. Metabolic acidosis results from bicarbonate loss or acid accumulation (e.g., diabetic ketoacidosis, renal failure, diarrhea). It is unrelated to ventilation. Hyperventilation from tachypnea does not cause metabolic acid-base changes.
B. Metabolic alkalosis occurs due to excess bicarbonate or acid loss (e.g., vomiting, diuretics). Increased ventilation does not affect bicarbonate levels directly, so tachypnea does not cause metabolic alkalosis.
C. Respiratory acidosis occurs when there is hypoventilation, causing CO2 retention. This patient is hyperventilating, which would lower CO2 rather than raise it, so respiratory acidosis will not occur.
D. Tachypnea combined with the ventilator in assist/control mode leads to excessive removal of CO2, lowering PaCO2. This produces respiratory alkalosis, a common complication when a patient breathes rapidly above the ventilator set rate.
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