A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain.
What safety measures should the nurse use to prevent client injury? (Select all that apply).

Advise the client to stay in bed and only get up with assistance.

Place the call bell in reach and respond promptly when activated.

Maintain the bed at working height for convenience when doing post op vital signs.

Keep the lights off to encourage client to rest and recuperate.

Attach the drain to wall suction and keep the tubing pinned to the client’s gown.

Answer and Explanation

Correct Answer : B

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Sensory deprivation is a condition in which a person experiences a lack of sensory input or stimulation.

This can result from isolation, confinement, or loss of sensory function. Sensory deprivation can cause psychological and physiological changes, such as irritability, confusion, paranoia, hallucinations, depression, anxiety, and cognitive impairment.

Choice A is wrong because mood disorder is a general term for a group of mental health conditions that affect a person’s emotional state, such as depression, bipolar disorder, or anxiety disorder. Mood disorder is not likely to be caused by isolation precautions for C diff.

Choice C is wrong because anxiety is a feeling of nervousness, worry, or fear that interferes with daily functioning. Anxiety can be triggered by stress, trauma, or other factors, but it is not a direct consequence of isolation precautions for C diff.

Choice D is wrong because cerebral vascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that causes neurological damage. CVA can cause symptoms such as weakness, numbness, slurred speech, vision loss, or confusion, but it is not related to isolation precautions for C diff.

A. Health promotion. B. Understanding of treatment options. C. Disease prevention. D. Eliminating the need for further care. E. Management of illness.

Correct Answer is ["A","B","C","E"]

Explanation

The goals of client teaching are to promote health, understand treatment options, prevent disease, and manage illness. These goals are established by the nurse and the client together, based on the client’s learning needs, preferences, and readiness. The nurse should use appropriate teaching strategies to help the client achieve these goals and evaluate the outcomes.

Choice D is wrong because eliminating the need for further care is not a realistic or attainable goal for most clients.

Clients may still need follow-up care, monitoring, or support after discharge. The nurse should not give false expectations or discourage the client from seeking help when needed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain. What safety measures should the nurse use to prevent client injury? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?

Correct Answer is B

Explanation

What does the nurse know to be the goals of client teaching? (Select all that apply).

Correct Answer is ["A","B","C","E"]

Explanation

Which serum laboratory test result should the nurse expect for a client diagnosed with Imbalanced Nutrition: Less than Body Requirements?

A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease. What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?

A client has undergone a surgical procedure and develops a weak, rapid pulse. Which intervention should the nurse recommend to provider during their SBAR communication?

Which statement provides the best documentation of the amount of wound drainage?

A client is to receive 250,000 units of benzathine penicillin. G. The medication is available in a vial containing 300,000 units per milliliter. How many milliliters should a nurse administer?

A health care provider has ordered vital signs every 4 hours. The client’s 8:00 AM temperature was 99° F (37.2° C). At 10 AM, the client reported chills. A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing. Which term is the appropriate choice to accurately document this lung sound?

Which assessment finding should a nurse record as a symptom of pain? A client who:.

A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain.
What safety measures should the nurse use to prevent client injury? (Select all that apply).