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. Muscular strength assessment: While muscular strength is important for overall mobility and health, it is not a key factor in wound healing. Wound healing is primarily influenced by oxygenation, perfusion, and nutrition.
B. Sensation assessment: While sensation is important in patients with conditions like diabetes (due to the risk of neuropathy and unnoticed wounds), it is not the most relevant assessment for determining wound healing.
C. Sleep assessment: Adequate rest is beneficial for healing, but sleep assessment is not the primary factor that determines wound healing. Other physiological factors play a greater role.
D. Pulse oximetry assessment: Oxygenation is a critical factor in wound healing. Low oxygen levels impair tissue repair, increase infection risk, and slow cell regeneration. Pulse oximetry assesses the oxygen levels in the blood, making it the most relevant assessment for wound healing.
Correct Answer is ["C","D"]
Explanation
A. Nonproductive cough: Diphenhydramine is an antihistamine, not a cough suppressant. It does not cause a nonproductive cough as a side effect.
B. Drowsiness: First-generation antihistamines (like diphenhydramine) cause CNS depression, leading to drowsiness.
C. Urinary retention: Diphenhydramine has anticholinergic effects, which can lead to urinary retention, especially in older adults or those with prostate issues.
D. Dry mouth: Diphenhydramine blocks muscarinic receptors, reducing saliva production and causing dry mouth.
E. Skin rash: Skin rash is not a common adverse effect of diphenhydramine but can be a sign of an allergic reaction.
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