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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
One drop left eye daily.
This is because it uses the correct abbreviation for left eye (os) and the correct frequency (daily).
The other choices are wrong because:
Choice A uses od which means right eye, not once daily.
Choice B uses ou which means both eyes, not each eye.
Choice C uses right ear which is not an eye drop medication. Some common eye drop prescription abbreviations are:
- gt or gtt for drop or drops
- od for right eye
- os for left eye
- ou for both eyes
- bid for twice a day
- tid for three times a day
- qid for four times a day
- prn for as needed
Correct Answer is B
Explanation
Self-determination. Self-determination is the ethical principle that respects the right of a person to make their own decisions. When a nurse respects the decision of a client who refuses a blood transfusion, the nurse is upholding this principle by acknowledging and protecting the client’s autonomy.
Choice A is wrong because beneficence is the ethical principle that involves actively seeking benefits or the promotion of good.
While a blood transfusion may be beneficial for the client, it is not the nurse’s role to impose their own judgment on the client’s choice.
Choice C is wrong because justice is the ethical principle that involves fairness and the just distribution of resources.
A blood transfusion is not a scarce resource that needs to be allocated among competing demands.
Choice D is wrong because fidelity is the ethical principle that involves keeping promises and being faithful to one’s commitments.
A blood transfusion is not a promise or a commitment that the nurse has made to the client.
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