The practical nurse (PN) observes a client’s initial postoperative dressing, which is saturated with serosanguinous fluid, and a drainage device that appears partially compressed. Which follow-up actions should the PN implement? (Select all that apply.).

The correct answers are Choice B and D: Choice B: Report the appearance of the dressing to the charge nurse, Choice D: Compress the drainage device before closing the tab. Choice A rationale: Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it. Choice B rationale: Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention. Choice C rationale: Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider. Choice D rationale: Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system. Choice E rationale: Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.