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) They bend at the ho when lifting:
This statement seems to be a typographical error, but it likely refers to "bending at the hips" when lifting. While bending at the hips can help reduce strain on the back, it is not the ideal body mechanic for lifting heavy objects. Proper lifting techniques involve bending at the knees, not the hips, to maintain proper alignment and reduce the risk of injury to the lower back. The correct form would be to squat down using the legs and keeping the back straight.

B) They keep their feet together when lifting an object:
Keeping the feet together when lifting an object is not advisable. The nurse should keep their feet shoulder-width apart for stability when lifting heavy objects. This wide stance provides a stable base and helps prevent loss of balance or strain during the lift. Keeping feet together would increase the risk of losing balance and possibly causing injury.

C) They stand close to the object being moved:
Standing close to the object being moved is the correct body mechanic. When lifting, the nurse should position themselves close to the object to minimize the leverage needed to lift it. By maintaining a short distance from the object, the nurse can use their legs to lift rather than relying on their back, which helps reduce the risk of back strain or injury.

D) They twist their spine when lifting:
Twisting the spine when lifting is a dangerous action that increases the risk of back injury. Proper body mechanics require that the nurse keep the back straight and avoid twisting the spine during the lift. Instead, they should rotate their whole body, moving their feet to turn, rather than twisting the spine. Twisting puts unnecessary stress on the spinal discs and can lead to muscle strain or injury.

A. Trough B. Peak C. Half-life D. Toxic

Correct Answer is A

Explanation

A) Trough:
The trough level refers to the lowest serum concentration of a medication in the bloodstream, typically measured just before the next dose is administered. This point is crucial for ensuring that drug levels remain within the therapeutic range and for avoiding toxicity. Monitoring the trough level helps healthcare providers determine whether the medication is being cleared appropriately from the system and whether dosage adjustments are needed.

B) Peak:
The peak level is the highest concentration of the medication in the bloodstream, typically measured shortly after the medication is administered. This is the opposite of the trough level. The peak level is important for assessing the maximum therapeutic effect of the medication but does not reflect the lowest concentration.

C) Half-life:
The half-life of a medication is the time it takes for the serum concentration of the drug to decrease by half. While it provides useful information about how long a drug stays in the body, it is not related to the lowest concentration of the drug. The half-life influences dosing intervals but is not directly tied to the concept of trough levels.

D) Toxic:
Toxic levels refer to the concentration of a medication in the blood that is high enough to cause harmful effects or toxicity. This is the opposite of the trough level, which represents the lowest safe level of the drug in the system. Toxicity occurs when drug levels exceed the therapeutic range, posing a risk to the patient’s health.

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