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    RN Comprehensive Predictor Proctored Exam (National U CA San Diego)

    A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

    Explanation & Rationale

    Rationale: A. Change the drainage tubing every 48 hr: Routine changing of drainage tubing is not recommended unless it becomes contaminated or occluded. Frequent manipulation increases the risk of infection and compromises the sterile system. B. Irrigate the drain to maintain suction: Irrigating a closed wound drainage system can introduce pathogens and disrupt the vacuum, increasing the risk of infection. Closed systems are designed to maintain suction without routine irrigation. C. Observe for drainage flow through the tubing: Monitoring the amount, color, and consistency of drainage is essential to assess wound healing and detect complications such as infection or hemorrhage. Observing flow ensures the system is functioning properly and provides critical data for clinical decisions. D. Remove the drain if output from the drain increases: Increased output can indicate ongoing bleeding or infection and should be reported to the provider. Premature removal of the drain in this situation could lead to fluid accumulation, wound dehiscence, or infection.

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