A nurse is caring for a group of patients on an adult medical-surgical unit.
Which patient should the nurse identify as having the highest risk for aspiration?

Choice A rationale:

This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.

It's important to validate the patient's experience and offer support, even if the pain level is not severe.

This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.

Choice B rationale:

This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.

Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.

Choice C rationale:

This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.

It is important to rule out any underlying medical conditions that may be causing the pain.

This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.

Choice D rationale:

This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.

This could lead to the patient feeling anxious or worried about their health.

It is important to investigate the cause of the pain before making any assumptions.

Choice A rationale:

Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.

It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.

It could also disrupt the delicate balance of fluids in the wound and delay healing.

Choice B rationale:

Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.

This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.

Choice D rationale:

Emptying the reservoir once per day is not frequent enough.

The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.

Allowing the reservoir to become too full could put pressure on the wound and impede healing.

Choice C rationale:

Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.

This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.