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 C
Explanation
Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.
Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.
Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.
Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.
Correct Answer is A
Explanation
“Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.” This indicates that the client understands that Clozaril (clozapine) is an antipsychotic medication that can affect the immune system and cause a serious blood disorder called agranulocytosis. The client needs to have regular blood tests to monitor the white blood cell count and prevent infections.
Choice B is wrong because Clozaril can cause urinary retention, not decreased urination. The client should be advised to report any difficulty or pain when urinating.
Choice C is wrong because Clozaril is not a PRN medication. It should be taken regularly as prescribed by the doctor to maintain a therapeutic level and prevent relapse of psychotic symptoms.
Choice D is wrong because Clozaril is not available over the counter or in a generic form. It is a controlled substance that requires a special program and a certified pharmacy to dispense it.
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