During handover, a nurse reports that a postoperative patient is pale, has a blood pressure of 84/50 mmHg, and has a rapidly increasing wound drain output. What should the receiving nurse do first?
Correct answer: B. Check the patient immediately and call for urgent assistance.
- A. Ask about the patient’s pain score before taking action.
- B. Check the patient immediately and call for urgent assistance.
- C. Complete the handover notes before visiting the patient.
- D. Offer oral fluids and reassess the patient after 30 minutes.
Explanation
Hypotension, pallor, and increasing drain output suggest possible postoperative haemorrhage, so circulation and immediate patient assessment are the priority. Completing paperwork, delaying review, or giving oral fluids can postpone urgent treatment and may be unsafe.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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