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","B","D","E","F"]

Explanation

Rationale:
A. Fundal height: The fundus has descended to 4 cm below the umbilicus and remains firm, indicating effective involution of the uterus and improvement from the previously boggy, tender fundus.

B. Heart rate: The client’s heart rate has decreased from 110/min on postpartum day 3 to 88/min on day 5, reflecting stabilization and decreased physiologic stress.

C. Hgb: Hemoglobin decreased slightly from 11.1 g/dL to 10 g/dL. While this is a minor drop, it does not indicate improvement and may reflect ongoing blood loss or hemodilution postpartum.

D. Temperature: The client’s temperature has normalized to 37.2° C (99° F) from febrile readings of 38.6° C (101.5° F), indicating resolution of the infection or inflammatory process.

E. WBC count: The WBC count decreased from 33,000/mm³ to 10,000/mm³, demonstrating resolution of the previous leukocytosis associated with infection or postpartum inflammation.

F. Lochia: Lochia has decreased in amount, is brownish-red without odor, indicating normal postpartum progression and resolution of the previously foul-smelling discharge, signifying improvement.

A. "You are feeling anxious now; why don't you give it some time before making a final decision? B. "You should talk with your family members before making this decision." C. "I will discuss this with your primary health care provider, and we can discuss this more tomorrow." D. "Let me refer you to talk to someone regarding your treatment options."

Correct Answer is D

Explanation

Rationale:
A. "You are feeling anxious now; why don't you give it some time before making a final decision?": This response minimizes the client’s feelings and delays addressing their emotional distress and right to autonomy. It fails to provide immediate therapeutic support.

B. "You should talk with your family members before making this decision.": While family involvement can be supportive, the client has the right to make autonomous decisions regarding treatment. Directing them to family first disregards the nurse’s role in providing professional support and resources.

C. "I will discuss this with your primary health care provider, and we can discuss this more tomorrow.": Although involving the provider is appropriate, postponing the discussion may neglect the client’s current emotional and psychological needs for immediate counseling and clarification.

D. "Let me refer you to talk to someone regarding your treatment options.": This response acknowledges the client’s concerns and facilitates support through referral to counseling, palliative care, or an ethics consult. This ensures the client’s emotional, psychological, and autonomy needs are appropriately addressed.

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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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