The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions should the nurse perform? (Select all that apply.)
a. Measure the amount of drainage in the device prior to emptying.
b. Label each drain and record them separately.
c. Recompress the device after emptying.
d. Secure the device to the patient's gown above the level of the wound.
e. Check for kinks in the tubing.
ANS: B, C, E
Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient's hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.
You might also like to view...
The nurse is caring for a patient receiving an oral fungicide to treat a systemic fungal infection. What intervention would the nurse include in the plan of care?
A) Maintain complete bed rest. B) Assess for cyanosis every 4 hours. C) Administer medication 1 hour before meals. D) Monitor nutritional status.
The family nurse practitioner is caring for a Hispanic female who is 83 years old. The patient has been noncompliant with the care regimen the nurse practitioner has previously outlined for treatment of sinusitis
What should the nurse practitioner do that can assist the patient in being more compliant with the prescribed treatment regimen? A) Provide instructions in the patient's language B) Provide the instructions in large font C) Give the treatment instructions to a member of the family D) Give the treatment instructions to the
A charge nurse notices that the 66-year-old nurse who works the shift has come to work with a black eye. The charge nurse is aware that the nurse lives with an adult grandson who has caused problems in the past. The charge nurse should:
1. Ignore the situation until the nurse shows a willingness to talk. 2. Notify security to approach the nurse about the situation. 3. Discuss the situation with the nurse in a private setting. 4. Ask the other staff members if abuse is involved.
The nurse pours the medication ordered for the client. The nurse asks the nurse assistant to give the medication when the client receives breakfast. Of which concept is this an example?
1. Ineffective delegation 2. Negligence 3. Vicarious liability 4. Decentralization