A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

Clean the skin near the drain in a circular motion from the outside to the inside.

Empty the drainage device when it is half full.

Place a perforated gauze pad around the drain to absorb drainage.

Connect the drain to continuous low-pressure suction

Answer and Explanation

The Correct Answer is C

A) Clean the skin near the drain in a circular motion from the outside to the inside:
When cleaning around a drain, the nurse should use a circular motion, but it is important to clean from the inside (near the drain) outward to prevent introducing bacteria into the drain site. Cleaning from the outside to the inside increases the risk of contaminating the wound and could cause infection.

B) Empty the drainage device when it is half full:
For a Penrose drain, the drainage is typically absorbed by a dressing rather than being collected in a drainage device. In general, for drains like Jackson-Pratt or Hemovac, emptying the device when it is half full is correct, but this is not applicable to a Penrose drain. A Penrose drain relies on passive drainage, and there is no reservoir that requires emptying.

C) Place a perforated gauze pad around the drain to absorb drainage:
A Penrose drain is an open drain that allows drainage of fluids from a wound or surgical site. A perforated gauze pad should be placed around the drain to absorb the drainage and keep the surrounding area clean and dry. This helps prevent infection and maintains a sterile environment around the wound.

D) Connect the drain to continuous low-pressure suction:
A Penrose drain does not require suction. It is a passive drain, relying on gravity to facilitate the drainage of fluid. Suction is typically used for other types of drains, such as Jackson-Pratt or Hemovac drains, which require a suction mechanism to actively draw out fluid.

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Correct Answer is B

Explanation

A) Chloride 112:
Chloride levels are typically not directly associated with numbness or tingling of the hands and fingers. Elevated chloride levels (greater than 108 mEq/L) may indicate metabolic acidosis, but they would not directly explain the symptoms seen in this client following parathyroidectomy. Therefore, this value is unlikely to be relevant in this scenario.

B) Calcium 7.5:
After the partial removal of the parathyroid glands, the client may experience hypocalcemia, or low calcium levels, due to the reduced production of parathyroid hormone (PTH). PTH helps regulate calcium levels in the blood. When the parathyroid glands are removed or damaged, there may be insufficient PTH to maintain normal calcium levels, leading to hypocalcemia. Symptoms of hypocalcemia include numbness and tingling, especially in the hands and fingers. A calcium level of 7.5 mg/dL is below the normal range (8.5–10.5 mg/dL), indicating hypocalcemia, which is consistent with the patient's symptoms.

C) Potassium 4.0:
A potassium level of 4.0 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not typically cause numbness or tingling. Although potassium imbalances can cause neuromuscular symptoms, they would not be the most likely cause of the symptoms in this case, especially in relation to parathyroidectomy.

D) Calcium 12.1:
A calcium level of 12.1 mg/dL is elevated and would suggest hypercalcemia. Hypercalcemia can cause symptoms like fatigue, confusion, and weakness, but it does not typically cause numbness and tingling in the hands and fingers. Elevated calcium levels are more likely to occur in conditions such as hyperparathyroidism or malignancy, not typically following parathyroid gland removal. Therefore, this is not the expected lab result in this scenario.

A. Provide a dedicated area for the nurse to prepare medications. B. Wait to document medications given to clients until the end of a shift. C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists. D. Prepare medications for multiple clients at the same time.

Correct Answer is A

Explanation

A) Provide a dedicated area for the nurse to prepare medications:
Having a dedicated, quiet area for preparing medications is crucial for reducing the risk of medication errors. A designated space minimizes distractions, ensures proper organization, and allows the nurse to focus on the task at hand, which can help prevent mistakes. It also supports a more organized environment where medications can be checked for accuracy, labels can be read carefully, and correct dosages can be administered. This is the best practice to reduce medication errors.

B) Wait to document medications given to clients until the end of a shift:
Delaying the documentation of medications until the end of a shift increases the risk of forgetting to document or making errors. Medications should be documented immediately after administration to ensure accuracy and prevent omissions. Immediate documentation also provides real-time updates on the client's medication history and avoids any discrepancies between what was actually administered and what is recorded.

C) Remove medications from automatic dispensing systems before they are reviewed by pharmacists:
Removing medications from automatic dispensing systems before they are reviewed by pharmacists increases the risk of errors. Medications should be reviewed by the pharmacist to ensure proper drug selection, dosage, and appropriateness for the patient's condition. Pharmacists play an essential role in medication safety, and bypassing their review increases the likelihood of incorrect medication administration, potentially leading to harmful consequences.

D) Prepare medications for multiple clients at the same time:
Preparing medications for multiple clients simultaneously is risky and can lead to confusion and errors. Nurses should focus on preparing medications for one patient at a time to ensure that the correct medication and dosage are administered to the correct person. This practice reduces the likelihood of mixing up medications or administering the wrong drug or dosage.

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A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

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