A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?
Replace the drainage plug after releasing hand pressure on the device.
Empty the reservoir once per day.
Fully recollapse the reservoir after emptying it.
Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
The Correct Answer is C
A. Replace the drainage plug after releasing hand pressure on the device:
Doing this allows air into the reservoir, preventing the vacuum effect. Plug should be replaced while still compressed.
B. Empty the reservoir once per day:
Reservoirs should be emptied at least every shift or when half full, not just once a day.
C. Fully recollapse the reservoir after emptying it:
This restores negative pressure, allowing continuous drainage and wound healing.
D. Irrigate the tubing with sterile normal saline solution at least once every 8 hr:
Irrigating the tubing is not standard care for closed-wound drains and can introduce infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Granulation tissue forming at the bottom of the wound bed:
Granulation tissue is associated with second intention healing, where the wound is open and heals from the base up.
B. Healing of the wound is prolonged:
First intention healing is typically faster and involves minimal tissue loss.
C. Wound is contaminated at the time of injury:
First intention healing usually involves clean, surgical wounds, not contaminated wounds.
D. Skin edges of the wound are sutured closed with edges that are well approximated:
This is characteristic of primary intention healing, where surgical or clean wounds are closed with sutures or staples.
Correct Answer is B
Explanation
A. Musty odor from the foam dressing upon removal:
A musty odor may indicate infection or colonization, not healing. Foam dressings should not have a strong odor unless there is concern for microbial growth.
B. Granulation tissue on the surface of the wound:
Granulation tissue is new connective tissue and capillaries that indicate active healing in a wound bed.
C. Peeling of the edges of the transparent dressing:
This can compromise the seal of the wound VAC and increase infection risk-not a sign of healing.
D. Sanguineous drainage in the suction device:
Some sanguineous drainage can be expected initially, but persistent bloody drainage is not a direct sign of healing.
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