In the first 2½ hours after a radical neck dissection, what is the first action a nurse should take when 40 mL of bloody fluid is collected?

In the first 2½ hours after a radical neck dissection, what is the first action a nurse should take when 40 mL of bloody fluid is collected?

• A. Obtain the vital signs
• B. Aspirate the fluid
• C. Administer pain medication
• D. Notify the physician

Answer: (A)

In the immediate postoperative period following a radical neck dissection, monitoring the patient's vital signs takes precedence. The collection of 40 mL of bloody fluid can be indicative of bleeding or a potential complication, and assessing vital signs provides critical information regarding the patient's hemodynamic status. Elevations in heart rate or drops in blood pressure could indicate a hypovolemic state due to blood loss, which would require immediate intervention. By obtaining vital signs first, the nurse can quickly evaluate whether the patient is stable or if there is a need for urgent actions such as fluid resuscitation or emergency intervention. While the other options could also play a role in patient care, they do not address the immediate need for assessing the patient's stability following a significant surgical procedure. This timely assessment can guide further action, ensuring that the patient receives the appropriate care promptly.

In the immediate postoperative period following a radical neck dissection, monitoring the patient's vital signs takes precedence. The collection of 40 mL of bloody fluid can be indicative of bleeding or a potential complication, and assessing vital signs provides critical information regarding the patient's hemodynamic status.

Elevations in heart rate or drops in blood pressure could indicate a hypovolemic state due to blood loss, which would require immediate intervention. By obtaining vital signs first, the nurse can quickly evaluate whether the patient is stable or if there is a need for urgent actions such as fluid resuscitation or emergency intervention.

While the other options could also play a role in patient care, they do not address the immediate need for assessing the patient's stability following a significant surgical procedure. This timely assessment can guide further action, ensuring that the patient receives the appropriate care promptly.