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. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications. B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion. C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely. D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider. E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.