A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Place the client in a right lateral side-lying position and elevate the head of the bed.

Compress the bulb with the tab open and then reinsert the tab into its opening.

Irrigate the drain tubing with 1 mL of NS, then close the opening with its tab.

Reinforce the incisional dressings and assess behind the neck for drainage.

Answer and Explanation

The Correct Answer is B

Choice A reason: Positioning right lateral with head elevation may shift fluid but does not restore drain suction. Compressing the bulb creates negative pressure, promoting drainage. Positioning is less effective, per surgical drain management and postoperative care standards in nursing practice.

Choice B reason: Compressing the bulb with the tab open, then reinserting it, restores negative pressure, enhancing drainage in the surgical drain. This ensures fluid removal, preventing hematoma or infection, per evidence-based surgical drain management and postoperative care protocols in nursing practice.

Choice C reason: Irrigating the drain with saline risks infection and is not standard for low drainage. Compressing the bulb restores suction, promoting drainage safely. Irrigation is inappropriate, per surgical drain management and infection control standards in postoperative nursing care.

Choice D reason: Reinforcing dressings and assessing drainage addresses symptoms, not the cause of low drainage. Compressing the bulb restores suction, increasing drainage effectively. Dressings are secondary, per surgical drain management and postoperative wound care protocols in nursing practice.

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Correct Answer is C

Explanation

Choice A reason: Changing tracheostomy ties every 48 hours maintains hygiene but is less critical than airway patency. Ties secure the tube, but obstruction from mucus or dislodgement risks respiratory failure. Regular patency checks ensure airflow, addressing the primary physiological need for oxygenation in tracheostomy care.

Choice B reason: Routine suctioning every 2 hours is unnecessary unless secretions obstruct the airway. Over-suctioning risks mucosal trauma or hypoxia. Assessing patency ensures the airway remains clear, guiding suctioning as needed, prioritizing respiratory function in tracheostomy clients over arbitrary suction schedules.

Choice C reason: Assessing airway patency every shift is critical, as tracheostomy tubes risk obstruction from mucus or dislodgement, causing respiratory distress. Regular checks confirm airflow, preventing hypoxia, addressing the physiological priority of oxygenation. This ensures timely intervention, maintaining airway integrity in clients with artificial airways.

Choice D reason: Cleaning the inner cannula daily prevents infection but is secondary to airway patency. Obstruction from secretions or tube displacement causes immediate respiratory failure. Patency assessment ensures airflow, guiding cleaning as needed, making it more urgent than routine cannula maintenance in tracheostomy care.

A. Looking at the client from the side, observe the size and shape of the chest wall. B. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. C. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Correct Answer is B

Explanation

Choice A reason: Observing chest wall shape assesses for abnormalities like barrel chest, not tactile fremitus. Fremitus involves feeling vocal vibrations, increased in pneumonia due to consolidated lung tissue. Visual inspection does not evaluate vibration transmission, making it irrelevant for assessing fremitus in suspected pneumonia.

Choice B reason: Tactile fremitus is assessed by placing the palm on the chest while the client speaks, feeling vibrations through consolidated lung tissue in pneumonia. Fluid-filled alveoli enhance sound transmission, increasing fremitus. This directly evaluates lung pathology, confirming consolidation, critical for diagnosing pneumonia’s extent and severity.

Choice C reason: Using a stethoscope assesses breathing sounds like crackles, not tactile fremitus, which requires palpation of vocal vibrations. While breath sounds aid pneumonia diagnosis, fremitus specifically evaluates consolidation via vibration, making stethoscope use incorrect for this physical assessment technique focused on lung tissue density.

Choice D reason: Compressing tissue for crackling assesses crepitus or subcutaneous emphysema, not fremitus. In pneumonia, fremitus increases due to consolidation, not tissue compression. This method is irrelevant, as fremitus relies on vocal vibration transmission through palpation, making it inappropriate for assessing pneumonia-related lung changes.

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A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Correct Answer is C

Explanation

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is B

Explanation

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