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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Researcher:
The nurse is gathering evidence-based practice (EBP) on catheter-associated urinary tract infections (CAUTI), which involves systematically collecting, analyzing, and reviewing existing studies or guidelines to inform clinical practice. This is the role of the researcher in EBP. Nurses in this role contribute to improving patient outcomes by identifying best practices, assessing existing evidence, and implementing findings to reduce complications, such as CAUTIs.
B) Nurse manager:
While a nurse manager may oversee quality improvement projects, staffing, and other operational aspects of nursing care, they are not typically the ones actively gathering evidence-based data themselves. Nurse managers may utilize the findings from research but are not directly involved in the research process unless leading specific studies.
C) Case manager:
A case manager primarily coordinates care for individual patients, ensuring they receive the appropriate resources and follow-up care. They help manage the continuity of care across different settings but do not focus on gathering or researching evidence for clinical practices. Their role is more focused on patient outcomes and care delivery rather than generating evidence.
D) Educator:
While an educator might be involved in teaching staff or patients about preventing CAUTI, the role described in the question specifically refers to gathering evidence-based practice information. Educators may use research findings in their teaching, but gathering evidence is a distinct activity that fits the role of the researcher in EBP.
Correct Answer is D
Explanation
A) "Break needles on syringes before disposal":
Breaking needles before disposal is not a safe practice because it increases the risk of injury to staff during disposal. Needles should be disposed of intact in designated sharps containers to prevent injury. Tampering with used needles or syringes could expose staff to bloodborne pathogens.
B) "Use two hands to recap a needle after administering a medication":
The use of two hands to recap a needle is a high-risk behavior and should be avoided. The proper procedure is to never recap a needle after use. If recapping is absolutely necessary, a one-handed technique using the cap or a mechanical device should be employed to reduce the risk of needlestick injuries. The best practice is to dispose of the needle immediately in a sharps container.
C) "Dispose of used razors in wastebaskets":
Used razors should never be disposed of in wastebaskets, as this poses a significant risk of injury to waste management personnel. Razors, like needles and other sharp objects, should be placed in a designated sharps container. These containers are puncture-resistant and provide a safe environment for the disposal of used sharp items.
D) "Replace sharps containers when they are 3/4 full":
Sharps containers should be replaced when they are 3/4 full to prevent overfilling, which increases the risk of needlestick injuries. Overfilled containers can also make it difficult to dispose of new sharps safely. It is essential to follow institutional guidelines for the proper disposal of sharps and ensure that containers are replaced in a timely manner to maintain a safe environment.
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