# Situation: A 74-year-old woman undergoes right total hip arthroplasty through a posterior approach for osteoarthritis. Orders include posterior hip precautions and weight bearing as tolerated. She lives with her son's family. At 18:00 on the day of surgery, the nurse reviews her closed wound drain: 14:00–16:00: 60 mL, dark red 16:00–17:00: 40 mL, dark red 17:00–18:00: 190 mL, bright red Her heart rate has risen from 84 to 112/min. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630442  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 74-year-old woman undergoes right total hip arthroplasty through a posterior approach for osteoarthritis. Orders include posterior hip precautions and weight bearing as tolerated. She lives with her son's family.

At 18:00 on the day of surgery, the nurse reviews her closed wound drain:
14:00–16:00: 60 mL, dark red
16:00–17:00: 40 mL, dark red
17:00–18:00: 190 mL, bright red
Her heart rate has risen from 84 to 112/min. What should the nurse do FIRST?

## 보기

1. Clamp the drain tubing to stop the loss of blood
2. Empty the drain and recheck the output in 1 hour
3. Reinforce the dressing and raise the head of the bed
4. Check her blood pressure and notify the surgeon now **✔ 정답**

**정답: 4**

## 해설

Drainage that suddenly changes from small amounts of dark blood to 190 mL of bright-red blood in an hour, with a rising heart rate, points to active hemorrhage. The nurse takes vital signs and notifies the surgeon immediately, without clamping or removing the drain.

## 심화 해설

Reading the drain trend
In the first hours after surgery the drain collected 60 mL over 2 hours, then 40 mL in an hour, all dark red, which is expected and decreasing. Between 17:00 and 18:00 the output jumped to 190 mL of bright red blood, and the heart rate rose from 84 to 112/min. A sudden increase in drainage, a change from dark to bright red, and a rising heart rate together point to active hemorrhage. The nurse's first action is to check the blood pressure and notify the surgeon now.

Why these findings matter
Dark red drainage reflects older blood that has collected in the wound. Bright red drainage indicates fresh arterial or brisk venous bleeding. The rising heart rate is the body's early compensation for falling blood volume; blood pressure often stays normal until a large volume is lost, so a normal reading would not be reassuring. Checking the blood pressure completes the picture for the surgeon, and immediate notification allows rapid assessment, laboratory tests, fluid or blood replacement, and possible return to the operating room.

| Time | Volume | Color | Interpretation |
| --- | --- | --- | --- |
| 14:00–16:00 | 60 mL | Dark red | Expected |
| 16:00–17:00 | 40 mL | Dark red | Decreasing, expected |
| 17:00–18:00 | 190 mL | Bright red | Active bleeding, with heart rate 112/min |

Why the other actions are unsafe
Clamping the drain does not stop the bleeding; it hides it and lets blood collect in the wound, forming a hematoma, and drains are not clamped without an order. Emptying the drain and rechecking in 1 hour delays treatment of a possible hemorrhage. Reinforcing the dressing does nothing for bleeding into the drain, and raising the head of the bed can worsen hypotension in a client who is losing volume.

Watch out! Do not wait for hypotension. Tachycardia with a sudden rise in bright red drainage is enough to act on. Waiting for the blood pressure to fall means waiting until compensation is failing.

Exam takeaway
While waiting for the surgeon, the nurse continues frequent vital signs, keeps the drain patent, assesses the dressing and the thigh for swelling, ensures intravenous access, and prepares for orders such as a complete blood count and type and crossmatch. Key point! A sudden rise in bright red wound drainage with tachycardia is active bleeding; check vital signs and notify the surgeon immediately, and never clamp the drain.

## 임상 시나리오

Postoperative Drain BleedingSudden bright red output
Drainage fell from 60 mL to 40 mL of dark blood, then jumped to 190 mL of bright red blood in one hour; heart rate rose from 84 to 112/min.

These findings indicate active hemorrhage. The nurse checks the blood pressure and notifies the surgeon now.

While waiting, the nurse keeps the drain patent, monitors vital signs, checks the thigh for swelling, and ensures intravenous access.

CautionNever clamp a wound drain to stop bleeding; it conceals blood loss and causes a hematoma.

## 핵심 개념

- **Closed wound drain** — A tube connected to a suction container that removes blood and fluid from a surgical wound.
- **Hemorrhage** — Rapid loss of a large amount of blood from a vessel.
- **Hematoma** — A collection of clotted blood within tissue.
- **Compensatory tachycardia** — An increased heart rate that maintains cardiac output when blood volume falls.

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