Which action is essential when assessing for drainage in a client with a large abdominal wound?
Feel the top of the client’s legs.
Examine area underneath the client.
Ask the client to cough forcefully.
Have the client sit up and lean forward.
The Correct Answer is B
This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.
Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.
Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.
Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.
Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
These choices validate the client with acute pain because they are signs of a sympathetic nervous system response to pain. Acute pain is a sudden and usually sharp sensation that indicates tissue damage or injury.
Choice B is wrong because dilated pupils are not a sign of acute pain. Pupils may dilate in response to fear, excitement, or drugs.
Choice C is wrong because constricted pupils are not a sign of acute pain. Pupils may constrict in response to bright light, drugs, or brain damage.
Choice F is wrong because decreased respirations are not a sign of acute pain. Respirations may decrease in response to relaxation, drugs, or respiratory depression.
Correct Answer is B
Explanation
The client on Digitalis has a low potassium level of 3.0 mEq/L, below the normal range of 3.5-5.0 mEq/L. Low potassium levels can increase the risk of digitalis toxicity, which can cause nausea, abdominal discomfort, visual changes, and cardiac arrhythmias.
The nurse would instruct the client to eat foods high in potassium, such as cantaloupe, to prevent or correct hypokalemia.
Choice A. Asparagus is wrong because asparagus is a low-potassium food that contains only 202 mg of potassium per cup.
Eating asparagus would not help to raise the client’s potassium level.
Choice C. Blackberries are wrong because blackberries are also a low-potassium food that contains only 233 mg of potassium per cup.
Eating blackberries would not help to raise the client’s potassium level.
Choice D. Cucumbers is wrong because cucumbers are a very low-potassium food that contains only 76 mg of potassium per cup.
Eating cucumbers would not help to raise the client’s potassium level and may even lower it further.
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