A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?
Irrigate the tubing with sterile normal saline solution at least once every 8 hours.
Replace the drainage plug after releasing hand pressure on the device.
Fully recollapse the reservoir after emptying it.
Empty the reservoir once per day.
The Correct Answer is C
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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.
In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.
It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.
Choice B rationale:
A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.
A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.
Choice C rationale:
A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:
Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.
A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.
Correct Answer is B
Explanation
Choice B rationale:
Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.
Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)
Infection
Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)
Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.
Choice A rationale:
Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.
Choice C rationale:
Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.
Choice D rationale:
Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.
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