,Question 60
Question: The practical nurse (PN) observes a client's initial
postoperative dressing and drain as seen in the picture. Which follow-up
actions should the PN implement? (Select all that apply.)
• A. Compress the drainage device before closing the tab.
• B. Remove the drainage device and apply a pressure dressing.
• C. Document the appearance of the wound as informed.
• D. Clamp the drainage tubing for the next four hours.
• E. Report the appearance of the dressing to the charge nurse.
Correct Answers: A, C, E Brief
Rationale:
A) Compress the drainage device before closing the tab: The
image shows a Jackson-Pratt (JP) drain. These must be
compressed to create the negative pressure (suction) required to
pull fluid from the wound.
C) Document the appearance of the wound as informed:
Accurate documentation of the initial postoperative dressing and
drainage is a standard nursing responsibility.
E) Report the appearance of the dressing to the charge nurse:
The dressing in the image shows significant sanguineous (bloody)
drainage. For an initial postoperative dressing, this should be
reported to ensure it is within expected limits and not indicative of
active hemorrhage.
,Final Answer
45
Rationale & Calculation
To fin d the correct infusion rate, you can use dimensional analysis or a
step-by-step conversion.
Step 1: Convert the concentration to like units
The IV bag contains 4 mg of norepinephrine in 1,000 mL. Since the
prescription is in micrograms (mcg), first convert the milligrams in the
bag to micrograms:
$$4\text{ mg} \times 1,000 = 4,000\text{ mcg}$$
So, the concentration is 4,000 mcg / 1,000 mL.
Step 2: Determine the mcg per hour
The client is prescribed 3 mcg/min. To find the hourly dose, multiply by
60 minutes:
$$3\text{ mcg/min} \times 60\text{ min/hr} = 180\text{ mcg/hr}$$
Step 3: Calculate mL per hour
Now, use the concentration to find the volume ( $V$) that delivers 180
mcg:
$$\frac{1,000\text{ mL}}{4,000\text{ mcg}} \times 180\text{ mcg/hr} =
X\text{ mL/hr}$$
Simplified:
$$\frac{1}{4} \times 180 = 45\text{ mL/hr}$$
,The correct answer to the question in the image is D. Adequate sunlight.
Rationale
Osteomalacia is a condition characterized by the softening of the bones,
typically caused by a severe deficiency in Vitamin D, calcium, or
phosphorus.
Correct Answer
A. Provide disposable training pants while calming the mother.
Rationale
In this clinical scenario, the nurse must prioritize immediate intervention
that addresses both the physical needs of the child and the emotional state
of the parent.
Question: The practical nurse (PN) observes a client's initial
postoperative dressing and drain as seen in the picture. Which follow-up
actions should the PN implement? (Select all that apply.)
• A. Compress the drainage device before closing the tab.
• B. Remove the drainage device and apply a pressure dressing.
• C. Document the appearance of the wound as informed.
• D. Clamp the drainage tubing for the next four hours.
• E. Report the appearance of the dressing to the charge nurse.
Correct Answers: A, C, E Brief
Rationale:
A) Compress the drainage device before closing the tab: The
image shows a Jackson-Pratt (JP) drain. These must be
compressed to create the negative pressure (suction) required to
pull fluid from the wound.
C) Document the appearance of the wound as informed:
Accurate documentation of the initial postoperative dressing and
drainage is a standard nursing responsibility.
E) Report the appearance of the dressing to the charge nurse:
The dressing in the image shows significant sanguineous (bloody)
drainage. For an initial postoperative dressing, this should be
reported to ensure it is within expected limits and not indicative of
active hemorrhage.
,Final Answer
45
Rationale & Calculation
To fin d the correct infusion rate, you can use dimensional analysis or a
step-by-step conversion.
Step 1: Convert the concentration to like units
The IV bag contains 4 mg of norepinephrine in 1,000 mL. Since the
prescription is in micrograms (mcg), first convert the milligrams in the
bag to micrograms:
$$4\text{ mg} \times 1,000 = 4,000\text{ mcg}$$
So, the concentration is 4,000 mcg / 1,000 mL.
Step 2: Determine the mcg per hour
The client is prescribed 3 mcg/min. To find the hourly dose, multiply by
60 minutes:
$$3\text{ mcg/min} \times 60\text{ min/hr} = 180\text{ mcg/hr}$$
Step 3: Calculate mL per hour
Now, use the concentration to find the volume ( $V$) that delivers 180
mcg:
$$\frac{1,000\text{ mL}}{4,000\text{ mcg}} \times 180\text{ mcg/hr} =
X\text{ mL/hr}$$
Simplified:
$$\frac{1}{4} \times 180 = 45\text{ mL/hr}$$
,The correct answer to the question in the image is D. Adequate sunlight.
Rationale
Osteomalacia is a condition characterized by the softening of the bones,
typically caused by a severe deficiency in Vitamin D, calcium, or
phosphorus.
Correct Answer
A. Provide disposable training pants while calming the mother.
Rationale
In this clinical scenario, the nurse must prioritize immediate intervention
that addresses both the physical needs of the child and the emotional state
of the parent.
