A client with autoimmune idiopathic thrombocytopenic purpura (ITP)has had a splenectomy and returned to the surgical unit 2 hours ago.The nurse assesses the client and finds the abdominal dressing saturated with blood.What action is most important?

Question

Quizplus · Accepted Answer

While some bloody drainage on a new surgical dressing is expected,a saturated dressing is not.This client is already at high risk of bleeding due to the ITP.The nurse should assess vital signs for shock and notify the surgeon immediately.The client may or may not need a transfusion.Reinforcing the dressing is an appropriate action,but the nurse needs to do more than document afterward.Removing the dressing increases the risk of infection; plus,it is not needed since the nurse knows where the bleeding is coming from.

A Client with Autoimmune Idiopathic Thrombocytopenic Purpura (ITP)has Had a Splenectomy