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 C

Explanation

A) Granulation tissue forming at the bottom of the wound bed:
Granulation tissue typically forms in wounds that heal by secondary intention. This type of healing occurs when the wound edges are not approximated (e.g., a large or open wound), and new tissue must form to fill the gap. In primary intention healing, the wound edges are well approximated, and granulation tissue is not the hallmark of the healing process, although some may appear early on.

B) Healing of the wound is prolonged:
Wounds healing by primary intention generally heal more quickly than those healing by secondary intention. In primary intention, the wound edges are approximated with sutures, staples, or adhesive, allowing for a faster and more efficient healing process. Therefore, prolonged healing is not expected with primary intention]

C) Skin edges of the wound are sutured closed:
This is the correct finding for a wound healing by primary intention. Primary intention healing occurs when the wound edges are brought together (approximated) and secured with sutures, staples, or adhesive strips. This method promotes faster healing and minimal scarring because the tissue is directly aligned.

D) Wound is contaminated at the time of injury:
Wounds that heal by primary intention are generally clean and not contaminated. If a wound is contaminated or infected at the time of injury, it is more likely to heal by secondary intention, where the tissue must fill in from the base upwards, which takes longer and may result in more scarring.

A. Increase in apart reflex B. Increase in muscle mass C. Decrease in body fat D. Decrease in systolic blood pressure

Correct Answer is A

Explanation

A) Increase in the startle reflex:
As people age, many of their physiological responses become less efficient, but some reflexes, such as the startle reflex, may actually become more pronounced or exaggerated. This occurs due to changes in the nervous system and decreased inhibition of certain reflex pathways. The startle reflex, which is an automatic response to sudden stimuli, can become more sensitive in older adults as a result of slower processing in the central nervous system.

B) Increase in muscle mass:
With aging, there is typically a decrease in muscle mass, a condition called sarcopenia, which leads to reduced strength and physical endurance. This loss of muscle mass starts around the age of 30 and accelerates after age 60. Therefore, muscle mass generally decreases rather than increases in older adults.

C) Decrease in body fat:
In older adults, body fat generally increases, particularly in the abdominal area, as muscle mass decreases and metabolism slows. While there may be some loss of subcutaneous fat in the face and extremities, visceral fat often increases, contributing to a higher body fat percentage.

D) Decrease in systolic blood pressure:
As people age, systolic blood pressure tends to increase, not decrease. This is due to the stiffening of the arteries and reduced elasticity of the vascular walls, which makes it harder for blood vessels to expand and contract with each heartbeat. This leads to a rise in systolic blood pressure while diastolic blood pressure may remain stable or decrease slightly.

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