Penrose Drain prepU assignment quiz PDF

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PrepU course work on questions and answers with answer rationales in full. All answers are correct and verified...

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Quiz Answers 1 The nurse is caring for a client who has a Penrose drain. On assessment, the nurse notes that there is a safety pin on the drain just outside the wound incision area. What action should the nurse take related to this finding? Time Spent - 00:02:14

Your Response: Remove the safety pin and clean with an antiseptic preparation. Correct Response: Document the presence and location of the safety pin. Rationale: The nurse should document the presence and location of the safety pin, because this is an expected finding. Many times, the surgeon will use a large safety pin inserted into the Penrose drain just outside of the wound to hold the drain in place and prevent it from slipping into the wound. Because this is an expected finding, the other options would not be correct actions to take. Remediation: For further review, read "Skill 8-6: Caring for a Penrose Drain." 2 When removing the old dressing from the site of a Penrose drain, the nurse notes that some of the dressing material has stuck to the client's skin. What action should the nurse take next? Time Spent - 00:01:26

Your Response: Apply sterile saline to loosen the dressing material from the skin. Rationale: The nurse should apply sterile saline to loosen the dressing material from the skin. If any part of the dressing sticks to the underlying skin, the nurse should use small amounts of sterile saline to help loosen and remove it. Sterile saline moistens the dressing for easier removal and minimizes damage and pain. Gently pulling the dressing off without the saline will likely be painful and may cause irritation to the site. An alcohol based adhesive remover is to remove tape or other adhesive materials. Remediation: For further review, read "Skill 8-6: Caring for a Penrose Drain." 3 A nurse is assisting a surgeon who will be placing a hollow, openended rubber tube in a client with an abscess to drain the wound. This drain will be placed such that one end will be in the abscess and the other will pass through an opening in the skin known as a stab wound. The nurse recognizes that which type of drain is needed? Time Spent - 00:00:06

Your Response: T-tube drain Correct Response: Penrose drain

Rationale: A Penrose drain is a hollow, open-ended rubber tube. It allows fluid to drain via capillary action into absorbent dressings. Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin, directly through the incision or through a separate opening referred to as a stab wound. A biliary drain, or T-tube, is sometimes placed in the common bile duct after removal of the gallbladder (cholecystectomy) or a portion of the bile duct (choledochostomy). The tube drains bile while the surgical site is healing. A Jackson–Pratt (J–P) or grenade drain collects wound drainage in a bulblike device that is compressed to create gentle suction. It consists of perforated tubing connected to a portable vacuum unit. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery. The drain consists of perforated tubing connected to a portable vacuum unit. Remediation: For further review, read "Skill 8-6: Caring for a Penrose Drain." 4 What is the best way for the nurse to clean the wound site in a client with a Penrose drain? Time Spent - 00:00:33

Your Response: in a circular motion beginning at the pin site and moving outward toward the edge of the wound Rationale: The best way is to clean the site using a circular motion beginning at the pin site and moving outwards. The nurse should begin at the drain insertion site and slowly move in a circular motion toward the outside or periphery of the drain site. This helps to ensure that cleaning is done from the cleanest area of the wound site or drain site to least clean areas and does not contaminate the wound. Using a wedge pattern or an up-and-down pattern is more likely to cause contamination of the wound as the nurse cleans from the cleanest area, out to the least clean and then returns to most clean areas to repeat the procedure possibly bringing bacteria or other contaminants to the wound area. Using a circular motion beginning at the outer edge of the wound would be cleaning from the most contaminated area into the least contaminated area putting the client at increased risk of infection. Remediation: For further review, read "Skill 8-6: Caring for a Penrose Drain." 5 The nurse need to place a dressing under and around a Penrose drain. Which dressing would be best for the nurse to obtain? Time Spent - 00:00:29

Your Response: A precut 4 × 4 sterile drain sponge Rationale: The nurse should obtain the presplit drain sponge to place under and around the drain. The sterile 2 × 2 gauze sponge is too small and does not have a precut split to allow it to go under and around the drain. Nonadherent petrolatum dressing gauze is medicated, which is not indicated. A roll of sterile prewoven gauze is also not precut and would not fit properly around the drain. Gauze should never be cut by the nurse to fit around a drain or stoma site, because this can cause fibers to get into the wound or stoma....