A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse perform to assess the amount of drainage?
Mark the drainage output on the collection chamber every 48 hours.
Strip the chest tube vigorously to dislodge blood clots.
Maintain the collection chamber below the client’s chest.
Add water to the water seal chamber as it evaporates.
The Correct Answer is C
Choice A reason: Marking drainage output every 48 hours is too infrequent to accurately assess drainage in a closed wound drainage system. Frequent monitoring (e.g., every shift) is needed to track output, detect complications like excessive bleeding, and ensure system functionality, making this intervention inadequate for assessment.
Choice B reason: Stripping the chest tube vigorously is not recommended, as it can increase intrathoracic pressure, risking tissue damage or bleeding. It does not assess drainage amount but manipulates the tube, potentially causing harm. Assessment requires observing output in the collection chamber, making this action incorrect.
Choice C reason: Maintaining the collection chamber below the client’s chest ensures proper drainage by gravity in a closed wound drainage system, like a chest tube. This position prevents backflow and allows accurate measurement of drainage output in the chamber, essential for assessing fluid loss and detecting complications like hemothorax.
Choice D reason: Adding water to the water seal chamber maintains system function but does not directly assess drainage amount. The water seal prevents air re-entry, not measures output. Assessment involves observing and recording drainage in the collection chamber, making this action irrelevant to the question’s focus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Using a cane provides stability and reduces fall risk for clients with multiple sclerosis, who often experience muscle weakness or balance issues. This assistive device promotes safe mobility, aligning with evidence-based safety strategies, making it the correct precaution for home care.
Choice B reason: Walking with feet close together decreases stability, increasing fall risk in multiple sclerosis due to impaired coordination. A wider stance is recommended for balance, making this precaution incorrect and potentially dangerous for the client’s safety.
Choice C reason: Avoiding orthotics is not advisable, as they can support mobility and prevent foot drop in multiple sclerosis. Orthotics improve safety and function, so discouraging their use is counterproductive, making this an incorrect recommendation for home safety.
Choice D reason: A rigorous range-of-motion exercise plan may cause fatigue or injury in multiple sclerosis, where moderated exercise is preferred. Overexertion exacerbates symptoms, so this plan is unsafe and inappropriate, making it incorrect for promoting client safety.
Correct Answer is C
Explanation
Choice A reason: Beneficence, acting for patient benefit, is not breached, as both clients receive care and supplies, albeit differently. Unequal distribution reflects access issues, not failure to promote well-being, making beneficence less relevant than justice in addressing this ethical concern.
Choice B reason: Nonmaleficence, avoiding harm, is not violated, as both clients access supplies without direct harm. The inequality in delivery method raises fairness concerns, not harm, making justice the primary ethical principle breached in this scenario of differential treatment.
Choice C reason: Justice, ensuring fair treatment, is breached when one client receives supplies directly and another must seek them externally due to insurance status. This inequality in resource access violates equitable care principles, critical in healthcare ethics to ensure fairness across patient populations.
Choice D reason: Autonomy, respecting patient choices, is not breached, as both clients receive care consistent with their needs. The issue lies in unequal resource access, not decision-making restrictions, making justice the relevant ethical principle over autonomy in this scenario.
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