The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.
Call the health care provider, a blockage is present in the tubing.
Remove the drain, a drain is no longer needed.
Do nothing as long as the evacuator is compressed
Chart the results on the intake and output flow sheet
The Correct Answer is A
A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).
B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.
C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.
D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Have you had any changes in your diet?" While diet can impact skin health, this question is not the most relevant for an immediate skin assessment. More direct questions about onset, symptoms, and exacerbating factors should be prioritized.
B. "Does your skin condition keep you awake at night?" Pruritus (itching), pain, or discomfort from a skin condition can disrupt sleep. Asking this helps assess the impact on daily life and quality of sleep.
C. "How does your skin condition make you feel?" Skin conditions can affect self-esteem and mental health. This question is therapeutic and appropriate to assess emotional impact.
D. "How do you handle stress?" Many skin conditions, such as eczema and psoriasis, worsen with stress. This question is relevant for identifying triggers.
Correct Answer is D
Explanation
A. "I will treat all the family members to be on the safe side." Treatment is only recommended for individuals who have active lice or close, prolonged contact with the infected child. Treating everyone unnecessarily may lead to overuse of medications.
B. "My child must be free from nits before returning to school." The CDC and AAP do not recommend "no-nit" policies, as nits alone do not indicate active infestation. Children can return to school after appropriate treatment begins.
C. "Toys that can't be dry cleaned or washed must be thrown out." Non-washable items should be sealed in a plastic bag for 2 weeks to kill lice, rather than being thrown away.
D. "All recently used clothing, bedding, and towels must be washed in hot water." Lice and nits can survive on fabric surfaces, so washing clothing, bedding, and towels in hot water (≥130°F/54°C) and drying on high heat is recommended to eliminate them.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.