A nurse is caring for a client.

Vital Signs

0800:

• Temperature 37.6° C (99.7° F)
• Blood pressure 108/56 mm Hg
• Heart rate 66/min
• Respiratory rate 18/min
• Pulse oximetry 97% on room air

0830:

• Temperature 37.5° C (99.5° F)
• Blood pressure 88/56 mm Hg
• Heart rate 104/min
• Respiratory rate 24/min
• Pulse oximetry 93% on room air

Select the 4 findings that require immediate follow-up.

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)

After administering an injection, a nurse should discard the needle in a puncture-proof container.
This is a recommended practice to ensure the safety of injections and related practices.
Choice A is wrong because removing the needle from the syringe is not necessary.
Choice B is wrong because recapping the needle before disposal is not recommended as it increases the risk of needlestick injuries.
Choice D is wrong because placing the needle on the bedside table poses a risk of injury and infection.