A postoperative client has an abdominal incision and a Penrose drain. Both are covered with an abdominal dressing. Which is an important nursing action associated with caring for a client with a Penrose drain?
Changing the soiled dressing carefully
Pinning the drain to the dressing
Allowing the drain reservoir to fill completely before emptying it
Maintaining the negative pressure of the drain
The Correct Answer is C
Choice A rationale: Changing the soiled dressing carefully is important but not specifically associated with caring for a Penrose drain.
Choice B rationale: Pinning the drain to the dressing is not typically done; securing the drain and preventing tension are important.
Choice C rationale: Allowing the drain reservoir to fill completely before emptying it is a crucial nursing action associated with caring for a Penrose drain.
Choice D rationale: Maintaining the negative pressure of the drain is not applicable to a Penrose drain, which relies on gravity drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Restlessness, confusion, and tachycardia are early signs of hypoxia, indicating inadequate oxygenation.
Choice B rationale: Bradycardia, dyspnea, and cyanosis are more indicative of advanced hypoxia.
Choice C rationale: Hypotension, vomiting, and cyanosis may suggest severe hypoxia or other medical issues but are not typically early signs.
Choice D rationale: Bradycardia, lethargy, and confusion are not typical early signs of hypoxia.
Correct Answer is C
Explanation
Choice A rationale: Heat therapy is generally contraindicated for a wound that is bleeding, as it can increase bleeding.
Choice B rationale: Heat therapy may not be appropriate for a client with impaired sensation due to the risk of burns.
Choice C rationale: The client who is experiencing spasms of the calf muscles can benefit from heat therapy, which can help relax the muscles and reduce pain. Heat therapy increases blood flow and oxygen delivery to the affected area, which promotes healing and reduces inflammation.
Choice D rationale: Heat therapy is contraindicated for the client who has an active, localized inflammation (D), because heat can worsen the inflammation and increase the risk of infection.
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