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 C
Explanation
Choice A reason: A pain level of 1 on a 0-10 scale indicates well-controlled pain, which does not directly impair wound healing. Adequate pain management supports mobility and recovery, reducing stress responses that could delay healing. This finding is not a risk factor for delayed wound healing in post-surgical clients.
Choice B reason: An oxygen saturation of 92% on room air is slightly low but not critically hypoxic. Wound healing requires adequate oxygenation, but levels above 90% are generally sufficient for tissue repair. This finding alone does not significantly indicate a risk for delayed wound healing compared to nutritional deficits.
Choice C reason: An albumin level of 2.5 g/dL (normal: 3.5-5.0 g/dL) indicates malnutrition, a major risk for delayed wound healing. Albumin is essential for tissue repair, collagen synthesis, and immune function. Low levels impair fibroblast activity and wound strength, increasing infection risk and slowing recovery in post-surgical clients.
Choice D reason: A body mass index of 22 is within the normal range (18.5-24.9) and does not indicate malnutrition or obesity, both of which can impair wound healing. Normal BMI supports adequate nutritional status for tissue repair, making this finding not a risk factor for delayed wound healing.
Correct Answer is A
Explanation
Choice A reason: Amniocentesis involves needle insertion through the uterine wall, which can irritate the uterus and trigger contractions, risking preterm labor at 33 weeks. Monitoring contractions is vital to detect early labor signs, enabling interventions like tocolytics to delay delivery. This protects the premature fetus, ensuring better outcomes by maintaining pregnancy until closer to term.
Choice B reason: Vomiting is not a typical amniocentesis complication. The procedure is localized to the uterus, with minimal systemic effects. Nausea may occur from anxiety, but vomiting is rare and not a priority for monitoring. Focus remains on uterine and fetal complications, like contractions or fluid leakage, which directly impact pregnancy safety and outcomes.
Choice C reason: Hypertension is not directly linked to amniocentesis. The procedure does not typically affect maternal cardiovascular function, as it’s a localized intervention. Monitoring for hypertension is more relevant for conditions like preeclampsia. Post-amniocentesis, the priority is uterine activity and fetal distress, not blood pressure, making this an irrelevant complication to monitor.
Choice D reason: Polyuria is not associated with amniocentesis, as the procedure does not impact renal function or fluid balance. The focus is on complications like contractions, bleeding, or amniotic fluid leakage, which pose direct risks to the pregnancy. Monitoring polyuria is unnecessary, as it does not reflect the procedure’s physiological effects or risks.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.