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 D

Explanation

Rationale:
A. Conduct the assessment before drying the newborn: Performing the assessment before drying exposes the newborn’s wet skin to cooler air and surfaces, increasing heat loss through evaporation, not conduction. The newborn should always be thoroughly dried immediately after birth to conserve body heat.

B. Check the newborn's rectal temperature every hr: Frequent temperature monitoring does not prevent heat loss; it only identifies hypothermia after it occurs. Additionally, rectal temperature measurement may cause mucosal injury and is not routinely recommended for newborns.

C. Place the newborn in an open crib for the initial assessment: Placing the newborn in an open crib exposes the infant to cooler air and surfaces, increasing heat loss through convection and conduction. The initial assessment should occur under a radiant warmer to maintain thermal stability.

D. Cover scale with warm blankets when weighing the newborn: Covering the scale prevents conduction heat loss, which occurs when the newborn’s skin comes into contact with cold surfaces. Using a warm blanket or pad ensures the infant’s body heat is preserved during weighing or handling.

A. Establish alternatives to verbal conversation. B. Provide educational materials with large print. C. Use a mechanical voice amplifier. D. Have the client's glasses brought from home.

Correct Answer is A

Explanation

Rationale:
A. Establish alternatives to verbal conversation: Expressive aphasia affects a person’s ability to produce speech, so using alternative communication methods—such as picture boards, writing tools, or gestures—helps the client express needs effectively.

B. Provide educational materials with large print: Large-print materials are helpful for clients with visual impairments, not speech difficulties. Since expressive aphasia is a language production disorder, adjusting text size does not facilitate communication or address the underlying deficit.

C. Use a mechanical voice amplifier: A voice amplifier is beneficial for clients who can speak but have weak vocal strength, such as those with vocal cord paralysis. It is ineffective for clients with expressive aphasia because the issue lies in word formation, not vocal volume.

D. Have the client's glasses brought from home: Glasses improve visual acuity but do not address the client’s difficulty in forming words or sentences. While ensuring clear vision is supportive, it does not directly enhance the client’s ability to communicate verbally.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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