A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

Clean the skin near the drain in a circular motion from the outside to the inside.

Empty the drainage device when it is half full.

Place a perforated gauze pad around the drain to absorb drainage.

Connect the drain to continuous low-pressure suction

Answer and Explanation

The Correct Answer is C

A) Clean the skin near the drain in a circular motion from the outside to the inside:
When cleaning around a drain, the nurse should use a circular motion, but it is important to clean from the inside (near the drain) outward to prevent introducing bacteria into the drain site. Cleaning from the outside to the inside increases the risk of contaminating the wound and could cause infection.

B) Empty the drainage device when it is half full:
For a Penrose drain, the drainage is typically absorbed by a dressing rather than being collected in a drainage device. In general, for drains like Jackson-Pratt or Hemovac, emptying the device when it is half full is correct, but this is not applicable to a Penrose drain. A Penrose drain relies on passive drainage, and there is no reservoir that requires emptying.

C) Place a perforated gauze pad around the drain to absorb drainage:
A Penrose drain is an open drain that allows drainage of fluids from a wound or surgical site. A perforated gauze pad should be placed around the drain to absorb the drainage and keep the surrounding area clean and dry. This helps prevent infection and maintains a sterile environment around the wound.

D) Connect the drain to continuous low-pressure suction:
A Penrose drain does not require suction. It is a passive drain, relying on gravity to facilitate the drainage of fluid. Suction is typically used for other types of drains, such as Jackson-Pratt or Hemovac drains, which require a suction mechanism to actively draw out fluid.

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Correct Answer is C

Explanation

A) Muscle mass:
Passive range of motion (ROM) exercises do not directly increase muscle mass. These exercises primarily help maintain joint function and flexibility rather than build muscle tissue, which requires active resistance exercises and strength training.

B) Bone density:
While weight-bearing activities can help improve bone density, passive ROM exercises do not have a significant impact on bone density. Passive ROM helps preserve joint function and flexibility but does not address the strengthening of bones.

C) Joint flexibility:
Passive ROM exercises are specifically designed to improve and maintain joint flexibility. These exercises involve the nurse or caregiver moving the client’s joints through their full range of motion without the client’s active participation. The goal is to maintain or increase the joint's flexibility and prevent stiffness, especially in patients who are unable to move their limbs actively, such as those who have had a stroke.

D) Muscle strength:
Passive ROM does not increase muscle strength because the client is not actively engaging their muscles. Muscle strength is built through active movements or resistance exercises, where the client’s muscles work against a force. Passive ROM helps maintain joint mobility, not muscle strength.

A. wait 10 sec after placing the probe before obtaining the oxygen saturation reading B. Place the sensor probe on the same extremity as an electronic blood pressure cuff C. Relocate the sensor every 8 hrs. D. Choose a finger with a capillary refill less than 2 sec.

Correct Answer is D

Explanation

A) Wait 10 sec after placing the probe before obtaining the oxygen saturation reading:
While a brief wait may be necessary for the pulse oximeter to adjust and display a stable reading, there is no need to wait a full 10 seconds after placing the probe before obtaining the reading. Typically, the device should provide an accurate reading within a few seconds after placement.

B) Place the sensor probe on the same extremity as an electronic blood pressure cuff:
The blood pressure cuff can interfere with the oxygen saturation measurement by constricting the blood flow to the extremity. Placing the pulse oximeter sensor on the same arm or hand as the blood pressure cuff could lead to inaccurate readings due to decreased circulation or occlusion of blood flow. It's best to place the pulse oximeter sensor on a different extremity from the cuff.

C) Relocate the sensor every 8 hrs:
This is not necessary unless there are signs of skin breakdown or compromised circulation under the probe. Typically, a pulse oximeter sensor can be left in place on a single site for several hours if it is well-tolerated by the patient. Frequent moving of the sensor could cause unnecessary discomfort or risk of skin irritation, and it's not a routine requirement.

D) Choose a finger with a capillary refill less than 2 sec:
The accuracy of pulse oximetry readings can be influenced by peripheral circulation. A finger with a capillary refill of less than 2 seconds indicates good peripheral perfusion, which is ideal for obtaining an accurate oxygen saturation measurement. Poor circulation, such as that seen with cold extremities or compromised blood flow, can lead to inaccurate readings, so ensuring the finger has adequate circulation is important.

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A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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