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 B

Explanation

Rationale:
A. Encourage the client to eat a large meal in the evening: Clients with myasthenia gravis experience progressive muscle weakness, especially later in the day. Eating large evening meals increases the risk of fatigue and aspiration because muscle strength is reduced after activity.

B. Recommend the client eat within 45 min of taking cholinesterase-inhibitor medication: Cholinesterase inhibitors, such as pyridostigmine, enhance neuromuscular transmission and improve muscle strength. Eating within 45 minutes of taking the medication ensures optimal swallowing ability and reduces the risk of aspiration by aligning mealtime with peak effect.

C. Recommend the client extend their neck to facilitate swallowing: Extending the neck actually increases the risk of aspiration by opening the airway. Clients should be instructed to flex the neck slightly forward while swallowing to close the airway and promote safe swallowing mechanics.

D. Encourage the client to contact an occupational therapist to learn techniques of avoiding aspiration: While an occupational therapist can provide helpful adaptive techniques, primary aspiration prevention teaching should come directly from the nurse and speech-language pathologist.

A. Obtain a 12-lead ECG for the client. B. Administer sublingual nitroglycerin to the client. C. Measure the client's vital signs. D. Have the client stop walking and sit down.

Correct Answer is D

Explanation

Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.

B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.

C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.

D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.

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