A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse perform to assess the amount of drainage?

Mark the drainage output on the collection chamber every 48 hours.

Strip the chest tube vigorously to dislodge blood clots.

Maintain the collection chamber below the client’s chest.

Add water to the water seal chamber as it evaporates.

Answer and Explanation

The Correct Answer is C

Choice A reason: Marking drainage output every 48 hours is too infrequent to accurately assess drainage in a closed wound drainage system. Frequent monitoring (e.g., every shift) is needed to track output, detect complications like excessive bleeding, and ensure system functionality, making this intervention inadequate for assessment.
Choice B reason: Stripping the chest tube vigorously is not recommended, as it can increase intrathoracic pressure, risking tissue damage or bleeding. It does not assess drainage amount but manipulates the tube, potentially causing harm. Assessment requires observing output in the collection chamber, making this action incorrect.
Choice C reason: Maintaining the collection chamber below the client’s chest ensures proper drainage by gravity in a closed wound drainage system, like a chest tube. This position prevents backflow and allows accurate measurement of drainage output in the chamber, essential for assessing fluid loss and detecting complications like hemothorax.
Choice D reason: Adding water to the water seal chamber maintains system function but does not directly assess drainage amount. The water seal prevents air re-entry, not measures output. Assessment involves observing and recording drainage in the collection chamber, making this action irrelevant to the question’s focus.

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Correct Answer is D

Explanation

Choice A reason: High-osmolarity formulas may cause diarrhea but are not directly linked to aspiration risk. Aspiration results from improper positioning or reflux, not formula osmolarity, so this factor is less relevant, making it incorrect for identifying aspiration risk in enteral feedings.
Choice B reason: Sitting in high-Fowler’s position (60-90 degrees) reduces aspiration risk by promoting gastric emptying and preventing reflux during enteral feedings. This is a protective measure, not a risk factor, making it incorrect for this scenario.
Choice C reason: A residual of 65 mL 1 hour postprandial is within acceptable limits (<100-200 mL, per facility protocol) and does not indicate high aspiration risk. Elevated residuals may suggest delayed emptying, but this value is normal, making it incorrect.
Choice D reason: A history of gastroesophageal reflux disease increases aspiration risk, as reflux can allow gastric contents to enter the airway during enteral feedings. This condition compromises esophageal sphincter function, making it a significant risk factor and the correct choice.

A. Avoid physical exercise to prevent fatigue. B. Take hot baths to relax muscles. C. Perform stretching exercises daily. D. Limit fluid intake to reduce bladder irritation.

Correct Answer is C

Explanation

Choice A reason: Avoiding physical exercise is not recommended for multiple sclerosis, as moderate activity like walking or stretching improves muscle strength, balance, and fatigue management. Complete avoidance leads to deconditioning, worsening mobility and fatigue, which are common in MS, making this instruction counterproductive to symptom management.
Choice B reason: Taking hot baths is not advised for multiple sclerosis, as heat can exacerbate symptoms like fatigue and muscle weakness due to temperature sensitivity (Uhthoff’s phenomenon). Cool or lukewarm baths are safer, supporting symptom control, making this instruction harmful and inappropriate for MS management.
Choice C reason: Performing daily stretching exercises improves flexibility, reduces spasticity, and enhances mobility in multiple sclerosis. Stretching strengthens muscles and prevents contractures, supporting functional independence. This aligns with evidence-based MS management to mitigate symptoms and improve quality of life, making it the correct instruction.
Choice D reason: Limiting fluid intake to reduce bladder irritation is inappropriate, as adequate hydration (2-3 L/day) prevents urinary tract infections, common in MS due to bladder dysfunction. Fluid restriction can worsen symptoms and dehydration, making this instruction incorrect for managing MS-related bladder issues effectively.

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A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse perform to assess the amount of drainage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is C

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