A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?

Irrigate the tubing with sterile normal saline solution at least once every 8 hours.

Replace the drainage plug after releasing hand pressure on the device.

Fully recollapse the reservoir after emptying it.

Empty the reservoir once per day.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.

It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.

It could also disrupt the delicate balance of fluids in the wound and delay healing.

Choice B rationale:

Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.

This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.

Choice D rationale:

Emptying the reservoir once per day is not frequent enough.

The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.

Allowing the reservoir to become too full could put pressure on the wound and impede healing.

Choice C rationale:

Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.

This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.

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Correct Answer is D

Explanation

The correct answer is choice d. Auscultate lung fields.

Choice A rationale:

Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.

Choice B rationale:

Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.

Choice C rationale:

Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.

Choice D rationale:

Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.

A. Distended neck veins B. Bounding pulse C. BP 146/94 mm Hg D. Urine specific gravity 1.034 .

Correct Answer is D

Explanation

Choice A rationale:

Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.

In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.

It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.

Choice B rationale:

A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.

A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.

Choice C rationale:

A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:

Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.

A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.

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