A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Place the client in a right lateral side-lying position and elevate the head of the bed.

Compress the bulb with the tab open and then reinsert the tab into its opening.

Irrigate the drain tubing with 1 mL of NS, then close the opening with its tab.

Reinforce the incisional dressings and assess behind the neck for drainage.

Answer and Explanation

The Correct Answer is B

Choice A reason: Positioning right lateral with head elevation may shift fluid but does not restore drain suction. Compressing the bulb creates negative pressure, promoting drainage. Positioning is less effective, per surgical drain management and postoperative care standards in nursing practice.

Choice B reason: Compressing the bulb with the tab open, then reinserting it, restores negative pressure, enhancing drainage in the surgical drain. This ensures fluid removal, preventing hematoma or infection, per evidence-based surgical drain management and postoperative care protocols in nursing practice.

Choice C reason: Irrigating the drain with saline risks infection and is not standard for low drainage. Compressing the bulb restores suction, promoting drainage safely. Irrigation is inappropriate, per surgical drain management and infection control standards in postoperative nursing care.

Choice D reason: Reinforcing dressings and assessing drainage addresses symptoms, not the cause of low drainage. Compressing the bulb restores suction, increasing drainage effectively. Dressings are secondary, per surgical drain management and postoperative wound care protocols in nursing practice.

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Correct Answer is B

Explanation

Choice A reason: A soft diet with milk products may worsen diverticulosis, as dairy can cause bloating or intolerance. High fiber and fluids prevent constipation, reducing diverticular pressure. This is inappropriate, per dietary management and gastrointestinal health guidelines for diverticulosis in nursing education.

Choice B reason: A high fiber diet and increased fluid intake prevent constipation, reducing pressure in diverticula and preventing complications like diverticulitis. This promotes bowel regularity, critical for managing diverticulosis, per evidence-based dietary recommendations and gastrointestinal health protocols in patient education for nursing care.

Choice C reason: Small frequent meals and sitting up after meals aid digestion but do not address diverticulosis-specific needs. High fiber and fluids directly prevent constipation, reducing diverticular strain. This is less effective, per dietary management and patient teaching standards for diverticulosis in nursing.

Choice D reason: A bland diet avoiding spicy foods is unrelated to diverticulosis, which requires fiber to prevent constipation. Spicy foods do not directly affect diverticula. High fiber and fluids are critical, per gastrointestinal health and dietary management guidelines for diverticulosis in nursing education.

A. Change the tracheostomy ties every 48 hours. B. Suction the tracheostomy every 2 hours routinely. C. Assess airway patency every shift. D. Clean the inner cannula with hydrogen peroxide daily.

Correct Answer is C

Explanation

Choice A reason: Changing tracheostomy ties every 48 hours maintains hygiene but is less critical than airway patency. Ties secure the tube, but obstruction from mucus or dislodgement risks respiratory failure. Regular patency checks ensure airflow, addressing the primary physiological need for oxygenation in tracheostomy care.

Choice B reason: Routine suctioning every 2 hours is unnecessary unless secretions obstruct the airway. Over-suctioning risks mucosal trauma or hypoxia. Assessing patency ensures the airway remains clear, guiding suctioning as needed, prioritizing respiratory function in tracheostomy clients over arbitrary suction schedules.

Choice C reason: Assessing airway patency every shift is critical, as tracheostomy tubes risk obstruction from mucus or dislodgement, causing respiratory distress. Regular checks confirm airflow, preventing hypoxia, addressing the physiological priority of oxygenation. This ensures timely intervention, maintaining airway integrity in clients with artificial airways.

Choice D reason: Cleaning the inner cannula daily prevents infection but is secondary to airway patency. Obstruction from secretions or tube displacement causes immediate respiratory failure. Patency assessment ensures airflow, guiding cleaning as needed, making it more urgent than routine cannula maintenance in tracheostomy care.

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A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

Correct Answer is B

Explanation

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Correct Answer is C

Explanation

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