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 A
Explanation
A. Give the medication in the morning daily. Montelukast (a leukotriene receptor antagonist) is given once daily in the evening for long-term asthma control. If prescribed for allergic rhinitis, it can be given in the morning.
B. Administer the medication 2 hours before exercise. Montelukast is not a rescue medication but a maintenance drug. However, it can be prescribed for exercise-induced bronchospasm and is taken at least 2 hours before exercise when used for that purpose.
C. Administer the granules mixed with 20 ounces of water. Montelukast granules should be mixed with a small amount of soft food (e.g., applesauce, mashed carrots) or breast milk/formula but not a large volume of liquid.
D. Give the medication at the onset of wheezing. Montelukast is not a quick-relief medication and does not work immediately. Short-acting bronchodilators (e.g., albuterol) should be used for acute wheezing.
Correct Answer is C
Explanation
A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.
B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.
C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.
D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.
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