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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Obtaining initial assessments requires clinical judgment and is outside the scope of assistive personnel (AP). Registered nurses must perform assessments to identify health changes accurately. Delegating this task violates scope of practice regulations, making it illegal and unsafe for AP to perform.
Choice B reason: Changing a nonsterile dressing is within the scope of assistive personnel, as it involves routine, non-invasive care under nurse supervision. AP are trained for such tasks, which do not require clinical judgment, making this a legal and appropriate delegation choice.
Choice C reason: Interpreting laboratory results requires advanced knowledge and clinical decision-making, reserved for registered nurses or providers. Assistive personnel lack the training to analyze results, so delegating this task is illegal and risks patient safety, making it an incorrect choice.
Choice D reason: Educating clients and families involves assessing learning needs and tailoring information, which requires nursing judgment. Assistive personnel are not trained for patient education, making this task outside their scope and illegal to delegate, thus an incorrect choice.

A. Suggest the client join a support group for people who have colostomies. B. Encourage the client and partner to avoid expressing negative feelings about the colostomy. C. Instruct the client’s partner to assume care of the colostomy for the client. D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

Correct Answer is A

Explanation

Choice A reason: Suggesting a support group helps the client address emotional resistance to the colostomy through peer support. This fosters psychological adjustment, reduces stigma, and promotes self-management by sharing experiences, aligning with evidence-based strategies to improve coping and adaptation in clients with new ostomies.
Choice B reason: Encouraging avoidance of negative feelings dismisses the client’s emotional response, hindering psychological adaptation. Accepting a colostomy requires processing grief and fear. Suppressing emotions delays coping, as psychological adjustment involves acknowledging feelings to integrate the stoma into the client’s self-image effectively.
Choice C reason: Instructing the partner to assume colostomy care undermines the client’s autonomy and delays self-management. Independence in stoma care is critical for psychological and practical adaptation. Dependency may hinder adjustment, as clients need to develop skills to manage their condition independently.
Choice D reason: Transferring to a rehabilitation facility is premature without trying in-hospital education or support groups. Most clients learn stoma care with nursing guidance. Transfer disrupts care continuity and may increase distress, failing to address emotional resistance directly, unlike peer support interventions.

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Naxlex Comprehensive Predictor Exams

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