The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.
Call the health care provider, a blockage is present in the tubing.
Remove the drain, a drain is no longer needed.
Do nothing as long as the evacuator is compressed
Chart the results on the intake and output flow sheet
The Correct Answer is A
A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).
B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.
C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.
D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Your disease often makes patients lose mental status." While severe hypoxia can cause confusion, this response does not address the reason for clubbing and lacks therapeutic communication.
B. "Your disease will be helped if you pursed-lip breathe." Pursed-lip breathing helps with air trapping and exhalation in COPD, but it does not explain clubbing of the fingers.
C. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." COPD primarily affects oxygen exchange in the lungs, not necessarily blood pumping from the heart. Clubbing is due to chronic hypoxia, not poor cardiac output.
D. "Your disease doesn't send enough oxygen to your fingertips." Chronic hypoxia in COPD leads to increased capillary growth and tissue changes, resulting in clubbing of the fingers. This response is accurate and appropriately explains the cause.
Correct Answer is C
Explanation
A. Hold the hands higher than the elbows. Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water.
B. Rub hands and arms to dry. Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination.
C. Apply 4 to 5 mL of liquid soap to the hands. The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult.
D. Adjust the water temperature to feel hot. Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.
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