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 A

Explanation

A) Holds their hands below the elbows while rinsing off soap:
This is the correct practice when performing hand hygiene. To prevent contamination, hands should be kept below the elbows while rinsing to allow the water and soap to flow downward and away from the clean hands. This helps to avoid contaminating the hands with water running down the forearms.

B) Uses hot water to wash their hands:
The temperature of the water should be warm, not hot. Hot water can irritate the skin and cause dryness, which may lead to skin breaks, a potential route for pathogen entry. Therefore, warm water is recommended for hand hygiene, as it is effective and more comfortable for the skin.

C) Turns off the faucet with their hands:
The faucet should be turned off using a paper towel or another method that avoids re-contaminating the hands after washing. Using clean hands to turn off the faucet would defeat the purpose of hand hygiene, as the faucet handle is a common area for bacterial contamination.

D) Washes their hands for 10 seconds:
The proper duration for washing hands is at least 20 seconds, not 10. This ensures that enough time is taken to properly clean all surfaces of the hands, including the palms, backs of hands, between fingers, and under fingernails. Shortening this time can lead to inadequate cleansing, leaving pathogens on the hands.

A. SOAP documentation B. Focus charting (DAR) C. Charting by exception (CBE) D. Problem-oriented medical record (POMR)

Correct Answer is C

Explanation

A) SOAP documentation:
SOAP (Subjective, Objective, Assessment, Plan) documentation is a method used for organizing and documenting client information. It focuses on both subjective and objective data, as well as the assessment and plan. While SOAP helps structure the documentation of patient conditions and interventions, it does not specifically focus on documenting only unexpected findings. It is a more comprehensive approach that includes normal and abnormal findings, not just the unexpected ones.

B) Focus charting (DAR):
Focus charting (DAR) is based on a client-centered approach and uses the components of Data, Action, and Response. It is a way of documenting observations and interventions, particularly in relation to specific patient problems or conditions. Focus charting is more about the care provided, responses to interventions, and client outcomes. While it may include unexpected findings, it doesn’t limit documentation exclusively to abnormal or unexpected events.

C) Charting by exception (CBE):
Charting by exception (CBE) is a documentation method that focuses on recording only the significant deviations from the norm. It emphasizes noting any abnormal or unexpected findings, and everything that is normal is assumed to be within expected limits and not documented. This method reduces the amount of documentation by excluding routine information and only highlighting significant, unexpected findings. Therefore, CBE is the correct answer in this scenario, as it involves documenting only unexpected or abnormal findings related to the client's condition.

D) Problem-oriented medical record (POMR):
POMR is a method of documentation that organizes client care around specific problems or diagnoses. It includes the identification of problems, interventions, and outcomes. While POMR focuses on client problems and plans of care, it does not specifically focus on documenting only unexpected findings. It may include both normal and abnormal findings related to each identified problem.

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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?

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