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 C

Explanation

Choice A reason: Raising the head of the bed during transfer does not prioritize ergonomic principles. It may strain the nurse’s back or misalign the client, increasing injury risk. Ergonomics focuses on neutral spine alignment and mechanical aids to reduce physical strain during client transfers.
Choice B reason: Placing pillows under the head is a comfort measure, not an ergonomic principle. Ergonomics emphasizes reducing musculoskeletal strain through proper mechanics or devices. Pillows do not directly prevent nurse injuries, unlike transfer devices that minimize physical effort during client movement.
Choice C reason: Using a lateral transfer device, like a slide board, aligns with ergonomic principles by reducing manual lifting and spinal strain. It prevents back injuries, ensuring safe client transfer. This evidence-based practice supports occupational health guidelines, minimizing musculoskeletal risks for nurses during patient handling.
Choice D reason: Standing close during ambulation ensures client stability but is not a primary ergonomic principle. Ergonomics focuses on equipment and mechanics to reduce strain, not proximity, which addresses patient safety more than nurse injury prevention during transfers or repositioning tasks.

A. Body mass index of 32 B. Temperature 36.8°C (98°F) C. White blood cell count 8,000/mm³ D. Blood glucose 90 mg/dL

Correct Answer is A

Explanation

Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.

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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 perform to assess the amount of drainage?

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