A nurse is caring for a 10-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?

Choice A reason:

The statement “Reposition the client a second time before assessing his respirations” is not appropriate in this scenario. If the client remains apneic after the initial airway repositioning, further repositioning is unlikely to be effective. Immediate action is required to determine the next steps in care.

Choice B reason:

The statement “Place a red tag on the client’s upper body and obtain immediate help from other personnel” is incorrect. A red tag is used for patients who require immediate medical attention and have a chance of survival with timely intervention. Since the client remains apneic despite airway repositioning, they are unlikely to survive without immediate advanced medical intervention, which may not be feasible in a mass casualty situation.

Choice C reason:

The statement “Place a black tag on the client’s upper body and attempt to help the next client in need” is correct. In a mass casualty incident, a black tag is used to indicate that a patient is deceased or expected to die due to the severity of their injuries and the lack of available resources to provide the necessary care. Since the client remains apneic with a weak pulse, they are unlikely to survive, and resources should be directed to those with a higher chance of survival.

Choice D reason:

The statement “Start CPR” is not the most appropriate action in this scenario. In a mass casualty situation, resources must be allocated to those who have the best chance of survival. Starting CPR on a client who remains apneic despite airway repositioning may not be the best use of limited resources, especially when other clients may need immediate attention and have a higher chance of survival.

Choice A reason:

The purpose of a Jackson-Pratt (JP) drain is not to eliminate the need for wound irrigations. Wound irrigation is a critical step in wound care that helps remove debris, reduce bacterial load, and create an optimal environment for healing. The JP drain helps manage fluid accumulation but does not replace the need for proper wound irrigation.

Choice B reason:

While a JP drain can help manage bleeding by providing a pathway for blood to exit the wound, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the accumulation of fluids such as blood, serous fluid, and other exudates that can impede healing and increase the risk of infection. Managing bleeding typically involves other interventions such as surgical hemostasis techniques.

Choice C reason:

The primary purpose of a Jackson-Pratt drain is to prevent fluid from accumulating in the wound. After surgery, wounds can produce various fluids, including blood and lymphatic fluid. Accumulation of these fluids can delay healing and increase the risk of infection. The JP drain uses gentle suction to draw these fluids away from the wound site, promoting faster healing and reducing the risk of complications.

Choice D reason:

A JP drain is not typically used to provide a means for medication administration. Medications are usually administered through other routes such as oral, intravenous, or through specialized catheters designed for medication delivery. The JP drain is specifically designed for fluid drainage and not for delivering medications.