While assessing a client who had a laparotomy the previous day, 300 ml of dark red fluids has drained from the nasogastric tube in the last hour. Which action should the nurse take first?

While assessing a client who had a laparotomy the previous day, 300 ml of dark red fluids has drained from the nasogastric tube in the last hour. Which action should the nurse take first?

• A. Determine the client's vital signs
• B. Monitor urinary output hourly.
• C. Notify the surgeon immediately.
• D. Assess the client's level of pain.

Answer: (A)

When there is a sign of potential internal bleeding after surgery, the immediate priority is to assess the patient’s circulatory status. Draining 300 mL of dark red fluid from the NG tube in one hour raises concern for postoperative hemorrhage, and the quickest way to gauge how the patient is handling this is to check vital signs. Determining heart rate, blood pressure, respiratory rate, oxygen saturation, and level of consciousness tells you whether the patient is compensating or showing signs of instability. If the vital signs reveal tachycardia, hypotension, or alterations in perfusion or mental status, this indicates hemodynamic compromise and you would urgently involve the surgeon and prepare for possible intervention. If vitals are stable, you still need to monitor closely, but the initial action remains the assessment of circulation. Urinary output and pain assessment are important for overall care, but they don’t provide the immediate evidence of stability needed here. Notifying the surgeon is essential when instability is detected, but you don’t escalate to that step without first assessing the patient’s vital signs.

When there is a sign of potential internal bleeding after surgery, the immediate priority is to assess the patient’s circulatory status. Draining 300 mL of dark red fluid from the NG tube in one hour raises concern for postoperative hemorrhage, and the quickest way to gauge how the patient is handling this is to check vital signs. Determining heart rate, blood pressure, respiratory rate, oxygen saturation, and level of consciousness tells you whether the patient is compensating or showing signs of instability. If the vital signs reveal tachycardia, hypotension, or alterations in perfusion or mental status, this indicates hemodynamic compromise and you would urgently involve the surgeon and prepare for possible intervention. If vitals are stable, you still need to monitor closely, but the initial action remains the assessment of circulation.

Urinary output and pain assessment are important for overall care, but they don’t provide the immediate evidence of stability needed here. Notifying the surgeon is essential when instability is detected, but you don’t escalate to that step without first assessing the patient’s vital signs.