Question

In the first 2.5 hours after a radical neck dissection, 40 ml of medium-red, bloody fluid is obtained from the client's drainage system. what should the nurse do? select all that apply.

Answer 1

After a radical neck dissection, the nurse should drain blood from the internal jugular and subclavian veins and monitor the client's vital signs.

Step-by-step explanation:

After a radical neck dissection, if the client's drainage system has obtained 40 ml of medium-red, bloody fluid in the first 2.5 hours, the nurse should take the following actions:

1. Drain blood from the right and left internal jugular veins.
2. Drain blood from the right and left subclavian veins.
3. Monitor the client's vital signs, such as blood pressure, heart rate, and oxygen saturation.

If the client is experiencing excessive bleeding or shows signs of hypovolemia, it is important for the nurse to address this immediately by providing appropriate blood products and fluids.

Answer 2

The nurse should assess the patient vital sign and notify the healthcare provider. For 2.5 hour after neck dissection, production of 40ml by the drainage is a bit excessive. There might be a bleeding in the site of operation that becomes the source of the drainage. Change dressing will not do anything. Applying pressure can be done if the site of bleeding is known.