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    ATI RN Comprehensive Per 2023 Proctored Exam

    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 of care?

    Explanation & Rationale

    Choice A reason: Checking patency every 8 hours is inadequate for closed wound drainage systems, which require more frequent monitoring (e.g., every 4 hours) to detect blockages. Delayed checks risk fluid buildup, increasing infection or seroma risk, critical in postoperative wound management. Choice B reason: Emptying the drainage system every 24 hours may be insufficient, as frequency depends on volume. Systems like Jackson-Pratt drains need emptying when half-full to maintain suction, preventing complications like infection, requiring flexible, volume-based schedules rather than fixed intervals. Choice C reason: Securing the drainage system to the gown prevents dislodgement, maintaining suction and reducing infection risk. It supports mobility while stabilizing the system, preventing wound tension. This is critical for effective drainage and healing in postoperative clients with closed systems. Choice D reason: Replacing the drainage system every 3 days is unnecessary unless infection or malfunction occurs. Routine replacement risks introducing pathogens or disrupting healing. Systems remain until drainage decreases, guided by clinical assessment, not a fixed schedule, to ensure safety.

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