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 A

Explanation

Choice A reason: Topical corticosteroids reduce eczema’s inflammation by inhibiting cytokines, alleviating antecubital vesicles. Heat lamps dry skin, worsening irritation and cracking. Encouraging steroids addresses the inflammatory pathophysiology, promoting healing, making this the most effective response for managing eczema and correcting harmful self-treatment.

Choice B reason: Chemical debridement is for necrotic tissue, not eczema’s inflammatory vesicles. Heat lamps exacerbate dryness, but debridement does not address immune-mediated inflammation. Corticosteroids target the cytokine-driven process, making debridement inappropriate for eczema’s pathophysiology, which requires anti-inflammatory treatment.

Choice C reason: Restricting heat to 15–20 minutes does not mitigate harm, as heat dries eczema lesions, disrupting the skin barrier and increasing infection risk. Corticosteroids reduce inflammation, addressing vesicles. Heat worsens epidermal damage, making this response ineffective compared to targeting the inflammatory cause.

Choice D reason: A sling for arm elevation is irrelevant for localized eczema, an inflammatory dermatitis, not edema requiring elevation. Heat lamps aggravate dryness, and corticosteroids treat inflammation, addressing immune-mediated pathology more effectively than positional changes, which do not impact eczema’s skin symptoms.

A. Obtain another measurement of the client’s blood pressure. B. Determine what medications the client recently received. C. Administer the antihypertensive medication as prescribed. D. Consult with the PN about the client’s condition at 0800.

Correct Answer is A

Explanation

Choice A reason: Obtaining another blood pressure measurement is critical, as lethargy, pallor, and diaphoresis suggest hypotension or shock, despite the earlier 140/90 reading. This guides safe administration of antihypertensives, preventing harm, per cardiovascular assessment and medication safety protocols in nursing practice.

Choice B reason: Determining recent medications is important but secondary to assessing current blood pressure, as symptoms suggest acute instability. Blood pressure confirms hypotension risk before reviewing drugs, ensuring timely intervention, per cardiovascular assessment and patient safety standards in nursing care.

Choice C reason: Administering antihypertensives without reassessing blood pressure is unsafe, as lethargy, pallor, and diaphoresis indicate possible hypotension. Confirming blood pressure prevents exacerbating instability, per medication safety and cardiovascular monitoring protocols in nursing practice for clients with hypertension.

Choice D reason: Consulting the PN about the 0800 condition delays immediate assessment of current symptoms. Blood pressure measurement addresses acute lethargy, pallor, and diaphoresis, guiding intervention. Consultation is secondary, per prioritization and cardiovascular assessment standards in nursing 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

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

Correct Answer is A

Explanation

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

Correct Answer is A

Explanation

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