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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["1"]

Explanation

Given:

Total daily dose of clonazepam: 1.5 mg

Frequency: Every 8 hours (3 doses per day)

Tablet strength: 0.5 mg

Step 1: Calculate the dose per administration:

Dose per administration = Total daily dose / Number of doses per day

Dose per administration = 1.5 mg / 3 doses

Dose per administration = 0.5 mg

Step 2: Determine the number of tablets per dose:

Number of tablets per dose = Dose per administration / Tablet strength

Number of tablets per dose = 0.5 mg / 0.5 mg/tablet

Number of tablets per dose = 1 tablet

A. Decreased peripheral pulses B. Heart rate 108/min C. Respiratory rate 10 breathes/min D. Dilated pupils

Correct Answer is B

Explanation

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1"]

Explanation

A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse in public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assessing a client who has a wound that is healing by primary intention. Which of the following findings should the nurse expect?

A nurse is teaching a newly licensed nurse about preventing puncture injuries, Which of the following instructions should the nurse include?

A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)