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

Chicken breast, green beans, and a glass of milk. This is because chicken breast is a good source of protein, which is essential for wound healing. Green beans are rich in vitamin C, which helps with collagen synthesis and immune function. Milk is a good source of calcium and vitamin D, which are important for bone health and healing.

Choice A is wrong because cheese pizza and french fries are high in fat and sodium, which can increase inflammation and delay wound healing. Orange juice is high in sugar, which can also impair wound healing and increase the risk of infection.

Choice B is wrong because cheeseburger and potato chips are also high in fat and sodium, and have similar effects as choice A. Soda is also high in sugar and can cause dehydration, which can slow down wound healing.

Choice D is wrong because spaghetti and meatballs are high in refined carbohydrates, which can spike blood sugar levels and impair wound healing.

A roll is also a refined carbohydrate and does not provide much fiber or nutrients. Chocolate pudding is high in sugar and fat, and can also worsen wound healing.

A. Fatigue related to excessive fluid loss. B. Deficient fluid volume related to dehydration. C. Risk for impaired skin integrity related to irritation. D. Imbalanced nutrition: less than body requirements related to vomiting.

Correct Answer is B

Explanation

This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-

being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.

Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.

It is not a priority over fluid volume deficit.

Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.

Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.

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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).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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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).