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 B
Explanation
Choice A rationale:
While explaining the importance and rationale of the new policy can be helpful, it may not address the underlying reasons for the nurse's resistance.
If the nurse does not understand or agree with the rationale, they may still be resistant to change.
Additionally, simply providing information may not create an open and trusting environment where the nurse feels comfortable expressing their concerns.
Choice B rationale:
Encouraging the nurse to verbalize their concerns allows the nurse manager to understand the specific reasons for the resistance.
This can help to identify any misconceptions or concerns that can be addressed directly.
It also gives the nurse an opportunity to feel heard and understood, which can help to build trust and rapport. When nurses feel that their concerns are being taken seriously, they are more likely to be open to change.
Choice C rationale:
Threatening disciplinary action is likely to create resentment and further resistance. It may also damage the relationship between the nurse manager and the nurse.
This approach should only be used as a last resort, after other attempts to address the resistance have failed.
Choice D rationale:
Ignoring the resistance is not an effective strategy.
It is likely to lead to continued noncompliance with the new policy,
It may also send the message that the nurse manager does not care about the nurse's concerns.
Peer pressure can sometimes be helpful in facilitating change, but it should not be relied upon as the sole strategy.
Correct Answer is B
Explanation
Choice B rationale:
Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:
Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.
Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.
Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.
Blood or secretions in the airway: These can obstruct the airway and cause stridor.
It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:
Oxygen therapy: This can help to improve the patient's breathing.
Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.
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