2. Advancing the drain by ¼ inch3. Checking the wound site for drainage from the drain4. Securing the drain by taping it firmly to bodyAnswer: 3Rationale:
Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red in color. Aseptic technique must be used when changing thedressing to prevent contamination of the wound, and sterile gloves are worn. The drainshould be checked for patency to provide an exit for the fluid and blood to promotehealing. The drainage needs to flow freely, and there should be no kinks in the drains.Curling, folding, or taping the drain prevents the flow of the drainage. The tube is notadvanced.Test-Taking Strategy:
Knowledge of the care of drains is necessary to answer thisquestion. Read each option carefully and visualize each option. Note that option 3 is theonly option that is a data collection action, the first step in the nursing process. Reviewnursing care to the client with a Penrose drain if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs:
Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReferences: Ignatavicius, D., & Workman, M. (2006).
Medical-surgical nursing:Critical thinking for collaborative care
(5th ed.). Philadelphia: W. B. Saunders, p. 350.Potter, P., & Perry, A. (2005).
Fundamentals of nursing
(6th ed.). St. Louis: Mosby, p.1507.1603. A nurse is assisting in caring for a client immediately following an abdominalsurgical procedure who lost a significant amount of blood during surgery. Which findingwould indicate a sign of a potential complication?1. Absent bowel signs2. A pulse rate of 90 beats/min3. A blood pressure of 120/70 mm Hg4. Increasing restlessnessAnswer: 4Rationale: Increasing restlessness noted in a client is a sign that requires continuous andclose monitoring because it could be indicative of a potential indication of acomplication, such as shock. Absent bowel sounds are a normal occurrence in theimmediate postoperative period following abdominal surgery. A blood pressure of 120/70 mm Hg with a pulse of 90 beats/min is a relatively normal sign.Test-Taking Strategy: Note the key words
lost a significant amount of blood
. Eliminate options 1, 2, and 3 because these are normal expectedfindings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications.Level of Cognitive Ability: AnalysisClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Fundamental SkillsReferences: Harkreader, H., & Hogan, M.A. (2004).
Fundamentals of nursing: Caring