A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

Change the drainage tubing every 48 hr.

Irrigate the drain to maintain suction.

Observe for drainage flow through the tubing.

Remove the drain if output from the drain increases.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Change the drainage tubing every 48 hr: Routine changing of drainage tubing is not recommended unless it becomes contaminated or occluded. Frequent manipulation increases the risk of infection and compromises the sterile system.

B. Irrigate the drain to maintain suction: Irrigating a closed wound drainage system can introduce pathogens and disrupt the vacuum, increasing the risk of infection. Closed systems are designed to maintain suction without routine irrigation.

C. Observe for drainage flow through the tubing: Monitoring the amount, color, and consistency of drainage is essential to assess wound healing and detect complications such as infection or hemorrhage. Observing flow ensures the system is functioning properly and provides critical data for clinical decisions.

D. Remove the drain if output from the drain increases: Increased output can indicate ongoing bleeding or infection and should be reported to the provider. Premature removal of the drain in this situation could lead to fluid accumulation, wound dehiscence, or infection.

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Correct Answer is A

Explanation

Rationale:
A. Provide a pacifier for nonnutritive sucking: Offering a pacifier promotes nonnutritive sucking, which supports oral motor development and provides comfort for the infant during gastrostomy tube feedings. This practice can help the infant transition more easily to oral feeding later.

B. Warm the formula in the microwave prior to administration: Warming formula in the microwave is unsafe because it can create hot spots that may burn the infant’s mouth or esophagus. Formula should be warmed using a bottle warmer or by placing the container in warm water.

C. Change the gastrostomy tube every 3 days: Routine gastrostomy tube replacement every 3 days is unnecessary and can cause trauma. Tubes are generally changed according to manufacturer recommendations or when malfunction or blockage occurs.

D. Place the infant in a supine position after the feeding: Infants should be kept in an upright or semi-upright position during and after feedings to reduce the risk of aspiration. Supine positioning increases the likelihood of reflux and respiratory complications.

A. Pain B. Dysphagia C. Fatigue D. Mottling

Correct Answer is A

Explanation

Rationale:
A. Pain: Persistent or severe pain in a client at the end of life indicates the need for a palliative care consultation. Palliative care focuses on symptom relief, comfort, and quality of life through interdisciplinary management, particularly when standard treatments fail to control pain effectively.

B. Dysphagia: While it requires assessment and dietary modification, it does not independently warrant a palliative consultation unless associated with uncontrolled distress or nutritional compromise.

C. Fatigue: Fatigue is a frequent symptom at the end of life, typically managed through rest, activity pacing, and supportive care. Although it contributes to discomfort, it is not the primary trigger for initiating palliative care unless it severely affects the client’s comfort.

D. Mottling: Mottling is a physical sign of imminent death resulting from decreased circulation. At this stage, palliative or hospice care is often already in place, and new consultation would not alter the course of care.

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A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

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