After surgery a patient's surgical dressing covering the Penrose drain is dry and intact.Two hours later,the patient reports pain of 5 on a scale of 0 to 10 at the incisional site and the dressing has a 1 ´ 1 inch area of serosanguineous drainage on the dressing.What actions should the nurse take? (Select all that apply.)

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Moderate serosanguineous drainage is expected from a Penrose drain,so monitoring the dressing is all that is needed at this time,as this is a small amount of drainage.The pain level requires intervention,and verifying the last time pain medication was administered is the first step.A.Pressure does not need to be applied to the incisional site.B.The drainage does not need to be cultured.C.The RN does not need to be notified.

After Surgery a Patient's Surgical Dressing Covering the Penrose Drain