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 C
Explanation
Chicken breast, green beans, and a glass of milk. This is because chicken breast is a good source of protein, which is essential for wound healing. Green beans are rich in vitamin C, which helps with collagen synthesis and immune function. Milk is a good source of calcium and vitamin D, which are important for bone health and healing.
Choice A is wrong because cheese pizza and french fries are high in fat and sodium, which can increase inflammation and delay wound healing. Orange juice is high in sugar, which can also impair wound healing and increase the risk of infection.
Choice B is wrong because cheeseburger and potato chips are also high in fat and sodium, and have similar effects as choice A. Soda is also high in sugar and can cause dehydration, which can slow down wound healing.
Choice D is wrong because spaghetti and meatballs are high in refined carbohydrates, which can spike blood sugar levels and impair wound healing.
A roll is also a refined carbohydrate and does not provide much fiber or nutrients. Chocolate pudding is high in sugar and fat, and can also worsen wound healing.
Correct Answer is ["B","D","E"]
Explanation
Choice A is wrong because women are more at risk for hip fractures than men.
This is partly because women lose bone density faster than men do, especially after menopause.
Choice C is wrong because an increase in estrogen will not weaken the bones. In fact, estrogen helps protect the bones from osteoporosis, which is a leading cause of hip fracture.
Some other risk factors for hip fracture include:
- Excessive alcohol and caffeine consumption
- Lack of physical activity
- Low body weight
- Tall stature
- Vision problems
- Dementia
- Medications that cause bone loss
- Cigarette smoking
- Institutional living, such as an assisted-care facility
- Increased risk for falls, related to conditions such as weakness, disability, or unsteady gait
Normal ranges for bone density vary by age and sex, but generally, a T-score of -1.0 or above is considered normal, while a T-score of -2.5 or below is considered osteoporotic. A T-score between -1.0 and -2.5 is considered osteopenic, which means low bone mass.
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