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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. AV Node: The AV node is responsible for delaying electrical impulses before they pass to the ventricles, but it does not generate the P wave. It affects the PR interval rather than the P wave itself.

B. SA Node: The SA (sinoatrial) node initiates electrical impulses and is responsible for atrial depolarization, which produces the P wave on an ECG. This makes it the correct answer.

C. Purkinje Fibers: The Purkinje fibers play a role in ventricular contraction (QRS complex), not in the formation of the P wave.

D. Bundle of HIS: The Bundle of HIS transmits impulses to the ventricles and is involved in ventricular depolarization, not atrial activity. It is not responsible for the P wave.

A. Disposable measuring tape B. Cotton-tipped applicator C. Natural light D. Sterile gloves

Correct Answer is C

Explanation

A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.

B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.

C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.

D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.

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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.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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