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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Rationale for Correct Choices
• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.
• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.
Rationale for Incorrect Choices
• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.
• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.
• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.
Correct Answer is B
Explanation
Calculation:
- Identify the client's weight in kilograms (kg) and height in meters (m).
Weight = 75 kg
Height = 1.8 m
- Calculate the square of the height in meters (m squared).
Height squared = 1.8 m x 1.8 m
= 3.24 m squared.
- Calculate the BMI.
BMI = Weight (kg) / Height (m squared)
= 75 kg / 3.24 m squared
= 23.148
- Round the answer to the nearest tenth.
= 23.1
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