The nursing assistant is caring for a client who returned an hour ago from surgery and has an indwelling urinary catheter, an intravenous line, and a hemovac wound drain in place. What observation would the nursing assistant report immediately to the nurse?

Question

Quizplus · Accepted Answer

The nursing assistant should immediately report that the wound drain (hemovac) is full of bloody drainage because that is a sudden large amount. It is not unusual that the client will be drowsy and may feel cold and want a blanket after surgery. It is not unusual for a small area of bloody drainage to be present on a dressing, and it may be reported, but not immediately. It is acceptable to have 100 mL of urine in an indwelling urinary catheter collection bag.

The Nursing Assistant Is Caring for a Client Who Returned