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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Free Nursing Study Resources

Correct Answer is ["10"]

Explanation

Set up the dosage calculation:

Desired dose:5 mg

Available dose:0.5 mg/tablet

We need to find out how many tablets will contain 5 mg of digoxin.

Use the formula:

Number of tablets = Desired dose (mg) / Available dose (mg/tablet)

Plug in the values and calculate:

Number of tablets = 5 mg / 0.5 mg/tablet

Number of tablets = 10 tablets

Round to the nearest whole number:

10 tablets

A. Diaphoresis B. Weight loss C. Hypotension D. Tachycardia

Correct Answer is D

Explanation

A) Diaphoresis:
While diaphoresis (excessive sweating) may occur with some cardiac or respiratory conditions, it is not a primary or expected sign of circulatory overload. Circulatory overload generally involves fluid accumulation in the body, and symptoms are more likely related to fluid retention and increased workload on the heart rather than sweating.

B) Weight loss:
Weight loss is not typically associated with circulatory overload. In fact, one of the hallmark signs of circulatory overload is weight gain due to fluid retention. The body retains excess fluid in the vascular system, leading to an increase in weight rather than weight loss.

C) Hypotension:
Hypotension (low blood pressure) is generally not associated with circulatory overload. Circulatory overload typically results in elevated blood pressure due to the increased volume of circulating fluid. In some cases, if the heart is unable to handle the increased volume, symptoms like pulmonary edema or shortness of breath can occur, but hypotension is more commonly seen in conditions like shock or severe fluid loss.

D) Tachycardia:
Tachycardia (an elevated heart rate) is a common finding in circulatory overload. When there is an excess of fluid in the body, the heart has to work harder to pump the additional volume of blood, leading to an increased heart rate. This is a compensatory response to the increased workload on the heart. It is also a sign that the body is attempting to maintain adequate tissue perfusion despite the excess fluid volume.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin 5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number, Use leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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