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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Improved sexual function:
While ACE inhibitors like lisinopril may have a beneficial impact on overall health, improved sexual function is not a direct therapeutic effect of this medication. In fact, ACE inhibitors can sometimes cause side effects like sexual dysfunction in some individuals. Therefore, improved sexual function is not considered a therapeutic outcome for lisinopril.
B) Decreased blood pressure:
Lisinopril is an ACE (angiotensin-converting enzyme) inhibitor that works by blocking the conversion of angiotensin I to angiotensin II, which results in vasodilation and lowered blood pressure. Therefore, a decreased blood pressure is the expected and desired outcome when a client is on lisinopril. This is the primary therapeutic effect of the medication.
C) Increase of HDL cholesterol:
Lisinopril does not have a direct effect on increasing HDL (high-density lipoprotein) cholesterol. While ACE inhibitors may have some indirect cardiovascular benefits, such as improving endothelial function or reducing risk factors for heart disease, raising HDL cholesterol is not one of their specific effects. This outcome would not indicate a therapeutic effect of lisinopril.
D) Prevention of bipolar manic episodes:
Lisinopril is not used for the treatment or prevention of bipolar disorder or its manic episodes. While certain medications, such as mood stabilizers or antipsychotics, may be used in the management of bipolar disorder, lisinopril is not effective for this purpose. Therefore, preventing bipolar manic episodes is not a therapeutic outcome of lisinopril.
Correct Answer is C
Explanation
A) Hypokalemia:
Hypokalemia (low potassium levels) is not a common adverse effect of labetalol. While some medications, such as diuretics, can lead to hypokalemia, labetalol does not typically affect potassium levels directly. Instead, labetalol's primary effects are on blood pressure and heart rate.
B) Bleeding:
Bleeding is not a typical adverse effect of labetalol. Labetalol is a beta blocker that works by blocking beta-adrenergic receptors, which lowers heart rate and blood pressure. It does not interfere with blood clotting or platelet function, so bleeding would not be a concern unless the patient is on other medications that affect coagulation (such as anticoagulants).
C) Bradycardia:
Bradycardia, or a slow heart rate, is a well-known and common adverse effect of beta blockers like labetalol. Labetalol works by blocking the beta-1 adrenergic receptors in the heart, which can reduce heart rate and lower blood pressure. In some individuals, this can result in bradycardia, which could lead to symptoms like dizziness, fatigue, and fainting.
D) Seizures:
Seizures are not a typical adverse effect of labetalol. Although central nervous system effects like dizziness or fatigue can occur due to the blood pressure-lowering effects, seizures are not commonly associated with this medication.
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