HESI EXIT TEST Full Answer Explanations for Questions 2024/2025

The nurse identifies bright red drainage, about 2.4 inches (6 cm) in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next? A. Mark the drainage on the dressing and take vital signs. B. Notify the healthcare provider of a potential for hemorrhage. C. Remove the dressing and assess the surgical incision site. D. Reassess dressing in one hour for increased drainage. - A. Mark the drainage on the dressing and take vital signs. Rationale Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the drainage on the dressing assists in determining an increase in the amount which is supported by any changes in vital signs that indicates possible internal bleeding.