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.

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Correct Answer is C

Explanation

Remove gloves, wash hands, remove face shield, gown, mask, and wash hands again. This is because gloves are the most contaminated piece of PPE and should be removed first to avoid touching other parts of the body or environment with them. Washing hands after removing gloves is also important to reduce the risk of infection. Face shields, gowns, and masks should be removed in that order, as they are less contaminated than gloves and can be handled with clean hands. Washing hands again after removing all PPE is the final step to ensure hygiene.

Choice A is wrong because it does not include washing hands after removing gloves, which is a crucial step to prevent contamination. It also removes the gown before the gloves, which can cause the gown to touch the face or hair and contaminate them.

Choice B is wrong because it does not include washing hands between removing gloves and gown, which can transfer germs from the gloves to the gown and then to the face or hair when removing the face shield and mask.

Choice D is wrong because it does not include washing hands between removing gloves and gown, which can transfer germs from the gloves to the gown and then to the face or hair when removing the face shield and mask. It also removes the gown before the face shield, which can cause the gown to touch the face or hair and contaminate it.

Normal ranges for PPE removal are not applicable as different types of PPE may require different methods of removal. However, some general principles are to remove PPE in a way that minimizes contact with contaminated surfaces, perform hand hygiene frequently, and dispose of PPE properly.

A. pH, 7.32; pCO2, 47 mm Hg; HCO3, 29 mEq/L; pO2, 80. B. pH, 7.34; pCO2, 49 mm Hg; HCO3, 27 mEq/L; pO2, 77. C. pH, 7.38; pCO2, 40 mm Hg; HCO3, 25 mEq/L; pO2, 88. D. pH, 7.48; pCO2, 43 mm Hg; HCO3, 23 mEq/L; pO2, 85.

Correct Answer is C

Explanation

This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.

Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.

Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.

Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.

The normal ranges for arterial blood gas (ABG) are:

pH: 7.35 – 7.45
pO2: 10 – 14 kPa or 75 – 105 mmHg
pCO2: 4.5 – 6 kPa or 34 – 45 mmHg

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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).

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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).