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 B

Explanation

Rationale:
A. "Avoid sexual intercourse for 7 days after receiving treatment.": HPV infections often persist in epithelial tissue even after visible lesions are treated, meaning transmission can still occur. Avoiding sexual contact for only 7 days does not eliminate the risk of spreading the virus.

B. "Obtain all recommended immunizations.": Receiving the HPV vaccine is the most effective method of preventing sexual transmission. The vaccine protects against high-risk HPV strains associated with cervical, anal, and oropharyngeal cancers, as well as genital warts. It is most effective when administered before sexual activity begins.

C. "Apply imiquimod ointment to any perineal ulcers.": Imiquimod is used to treat external genital warts caused by HPV, not perineal ulcers. Its use does not prevent infection or transmission and should only be applied to intact wart tissue under provider supervision.

D. "Undergo laser therapy to remove any lesions.": Laser therapy can remove visible warts but does not eradicate the virus itself. While it reduces the number of infectious lesions, HPV can still be transmitted through microscopic viral shedding even after lesion removal.

A. "Report bleeding that saturates the client's dressing." B. "Ensure the client's urinary output is no less than 20 mL per hour." C. "Expect the client to have a palpable distended bladder following surgery." D. "Maintain the client in a supine position for 24 hours following surgery."

Correct Answer is A

Explanation

Rationale:
A. "Report bleeding that saturates the client's dressing.": Excessive or saturating bleeding from a postoperative abdominal incision may indicate hemorrhage or disruption of the surgical site and requires immediate provider notification.

B. "Ensure the client's urinary output is no less than 20 mL per hour.": The expected minimum urinary output for an adult after surgery is at least 30 mL per hour, which reflects adequate renal perfusion and fluid balance. A urine output of 20 mL per hour is too low.

C. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected postoperatively and may signal urinary retention, a common complication due to anesthesia or opioids.

D. "Maintain the client in a supine position for 24 hours following surgery.": Keeping the client supine for 24 hours increases the risk of respiratory complications, including atelectasis and pneumonia. The nurse should encourage early ambulation and semi-Fowler’s positioning.

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 teaching a group of clients about ways to prevent sexual transmission of human papillomavirus. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Correct Answer is A

Explanation

A home health nurse is planning care for a client who has right-sided weakness following a recent cerebrovascular accident. The client reports feeling unsteady when walking. Which of the following interventions should the nurse include?

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take?

The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)

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 assisting a client who lives in a rural community with obtaining health services. Which of the following actions by the nurse demonstrates coordination of care?