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 D

Explanation

A) Heart failure:
While heart failure can cause a variety of symptoms, including shortness of breath, fatigue, and nocturnal respiratory disturbances, it is not a direct cause of obstructive sleep apnea (OSA). However, heart failure can exacerbate the effects of sleep apnea, particularly in individuals who already have OSA, leading to a condition known as "central sleep apnea with Cheyne-Stokes respiration.

B) Brainstem injury:
Brainstem injury can affect the regulation of breathing and may lead to central sleep apnea, where the brain fails to send the proper signals to the muscles that control breathing. However, brainstem injury does not directly cause obstructive sleep apnea, which is typically caused by physical blockages or obstructions in the upper airway.

C) Recent weight loss:
Recent weight loss is generally not associated with the development of obstructive sleep apnea. In fact, weight loss can sometimes reduce the severity of OSA in overweight or obese individuals. OSA is more commonly associated with excess weight and fat deposits around the neck and throat, which can contribute to airway obstruction during sleep.

D) Enlarged tonsils:
Enlarged tonsils, especially in children, are a well-known cause of obstructive sleep apnea (OSA). The enlarged tonsils can block the upper airway during sleep, leading to periods of apnea or hypopnea (reduced airflow). This obstruction can result in snoring, choking, and interrupted sleep.

A. Role-play B. Question-and-answer C. Discussion D. Return demonstration

Correct Answer is D

Explanation

A) Role-play:
Role-playing is a teaching strategy where the client or learner acts out a scenario or situation to practice certain behaviors, such as interacting with others in a social or clinical setting. In this case, the nurse is not asking the client to simulate a scenario or interact with others, but instead, to physically perform a specific task (walking with a walker).

B) Question-and-answer:
The question-and-answer method involves the nurse asking the client questions to assess understanding or clarify information. This method typically involves verbal interaction rather than performing a physical skill. In this scenario, the nurse is not simply asking questions, but rather observing the client as they perform the physical task of walking with a walker.

C) Discussion:
Discussion is a method of teaching where ideas or concepts are shared and discussed, often in a conversational format. While the nurse might use discussion as part of the overall teaching, the act of having the client physically demonstrate walking with a walker is a separate and more focused teaching strategy.

D) Return demonstration:
Return demonstration is the teaching strategy in which the nurse shows the client how to perform a task (such as walking with a walker) and then asks the client to perform the task themselves to confirm understanding and skill acquisition. This method allows the nurse to assess the client’s ability to perform the task correctly and ensures that the client has learned the skill effectively.

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