Which action is essential when assessing for drainage in a client with a large abdominal wound?
Feel the top of the client’s legs.
Examine area underneath the client.
Ask the client to cough forcefully.
Have the client sit up and lean forward.
The Correct Answer is B
This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.
Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.
Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.
Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.
Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.
Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.
Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.
Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.
Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.
Correct Answer is B
Explanation
“I apologize for not hearing you say that. Is there a better day for you?”.
This response shows empathy and respect for the client’s feelings and preferences.
It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.
It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.
It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.
Choice D is wrong because it is persuasive and manipulative.
It does not address the client’s concerns or explore other options.
The nurse-client relationship is based on trust, respect, and collaboration.
The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.
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