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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. The client agreed to the procedure voluntarily: By witnessing the signature, the nurse verifies that the client is signing the consent form without coercion, fulfilling the legal requirement that consent is given voluntarily. This does not require the nurse to provide detailed explanations of the procedure.

B. The nurse explained the surgical procedure in detail: The responsibility for explaining the procedure, risks, and benefits lies with the surgeon or provider, not the nurse witnessing the consent. Witnessing only confirms voluntary agreement.

C. The nurse explained the risks and benefits of the surgery: Explaining risks and benefits is the provider’s legal obligation. The nurse’s role is to witness the client’s signature, not to provide detailed medical explanations.

D. The client knows they may no longer refuse the procedure: Clients always retain the right to refuse a procedure, even after signing consent. Witnessing does not override the client’s autonomy or ability to change their mind.

A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body. B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field. C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field. D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container.

Correct Answer is D

Explanation

Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.

B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is witnessing a surgeon obtain informed consent from a client. Which of the following legal requirements is met by this action?

Correct Answer is A

Explanation

A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A group of nurse managers is discussing cost effectiveness with hospital administrators. Which of the following statements indicates a strategy for cost effectiveness?

A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?

A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?

A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?

A nurse is caring for a client in the outpatient health clinic. Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.