A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?
There is no redness, warmth, or drainage at the insertion site.
Drainage from the surgical site is 30 mL less than yesterday.
The patient reports adequate pain control with medications.
Urine is clear yellow and urine output is greater than 40 mL/hr
The Correct Answer is A
A. There is no redness, warmth, or drainage at the insertion site.
This assessment is crucial for evaluating the status of the abdominal drain site. The absence of redness, warmth, or drainage suggests that the insertion site is healing well without signs of infection or inflammation. It indicates that the drain is functioning properly and that there are no immediate complications related to the drain insertion. This assessment directly addresses the goals related to monitoring the drain site for signs of infection or dysfunction.
B. Drainage from the surgical site is 30 mL less than yesterday.
Monitoring the drainage output from the surgical site is important to assess for changes in drainage patterns. A decrease in drainage volume may indicate reduced fluid accumulation at the surgical site, potentially reflecting improved healing and decreased need for drainage. However, while this assessment is valuable, it is not as directly related to assessing the status of the drain itself or evaluating complications at the insertion site as option A.
C. The patient reports adequate pain control with medications.
Pain control is an essential aspect of postoperative care, but it is not specifically related to assessing the functionality or complications of the abdominal drain. While pain management is important for patient comfort and recovery, it does not directly address the goals related to monitoring the drain site for signs of infection, leakage, or other complications.
D. Urine is clear yellow, and urine output is greater than 40 mL/hr.
While monitoring urine output and characteristics is important for assessing renal function and hydration status, it is not directly related to assessing the abdominal drain or its complications. Clear yellow urine and adequate urine output are generally positive indicators but do not provide specific information about the functionality or status of the drain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Loose connective tissue:
Melanocytes are not typically found in loose connective tissue. Their primary location is within the epidermis, specifically in the basal layer, where they interact with keratinocytes to produce melanin and contribute to skin color. Loose connective tissue contains collagen and elastin fibers, as well as fibroblasts, but it does not house melanocytes.
B. Epidermis:
This is the correct answer. Melanocytes are primarily located in the basal layer of the epidermis, which is the deepest layer of the epidermis. These cells produce melanin, a pigment that helps protect the skin from UV radiation and determines skin color. Melanocytes are interspersed among keratinocytes in the epidermis and transfer melanin to keratinocytes to provide skin pigmentation.
C. Dermis:
The dermis is the layer of skin beneath the epidermis and consists of connective tissue, blood vessels, nerves, hair follicles, and sweat glands. While the dermis plays a crucial role in supporting and nourishing the epidermis, melanocytes are not primarily located in the dermis. They are confined to the basal layer of the epidermis.
D. Superficial fascia:
The superficial fascia, also known as the subcutaneous tissue or hypodermis, lies beneath the dermis and consists of adipose (fat) tissue and connective tissue. It provides insulation, energy storage, and cushioning for underlying structures. However, melanocytes are not typically found in the superficial fascia. They are restricted to the epidermis, specifically the basal layer, where they carry out their function of melanin production.
Correct Answer is D
Explanation
A. A 60-year-old client with gastritis:
Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.
B. A 20-year-old client with a closed tibia fracture:
A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.
C. A 55-year-old client taking an ACE inhibitor:
ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.
D. A 35-year-old client receiving chemotherapy:
Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.
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