What is an appropriate technique for the nurse to implement for ...

[student77]

What is an appropriate technique for the nurse to implement for drainage evacuation?
 
  a. Replace the Hemovac drain fully expanded.
  b. Attach the drainage tubing to the patient's gown.
  c. Tilt the evacuator of the Hemovac away from the plug.
  d. Complete the dressing change before the drainage evacuation.

Question 2

Measurement of the systolic blood pressure begins when:
 
  A. The cuff is deflated
  B. The first sound is heard
  C. The sound muffles
  D. The sound disappears

[shaquita]

Answer to Question 1

B
Pinning drainage tubing to the patient's gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times.

Answer to Question 2

B
B. Note point on manometer when first clear sound is heard. The sound will slowly increase in intensity. First Korotkoff sound reflects systolic blood pressure.
A. Slowly release pressure bulb valve, and allow manometer needle to fall at rate of 2 to 3 mm Hg/sec.
C. Place stethoscope earpieces in ears and be sure sounds are clear, not muffled. Earpieces should follow angle of ear canal to facilitate hearing.
D. Continue to deflate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mm Hg. Listen for 10 to 20 mm Hg after the last sound. Beginning of the fifth Korotkoff sound is recommended as indication of diastolic pressure in adults.

[student77]

Gracias!

[dantucker]

TYSM