While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?.
Leave it until the end of the shift.
Remove the drain.
Empty the reservoir.
Notify the surgeon about the blood loss.
Correct Answer : C
Leaving the drain until the end of the shift is not appropriate because it could lead to complications such as:
- Hematoma formation: Blood accumulation in the tissues surrounding the drain can put pressure on surrounding structures, potentially impairing blood flow and causing tissue damage.
- Infection: A reservoir containing blood provides a favorable environment for bacterial growth, increasing the risk of infection.
- Drain occlusion: Clotted blood can block the drain, preventing effective drainage and leading to fluid buildup and potential infection.
- Decreased wound healing: Excessive blood loss can delay wound healing by depriving the tissues of necessary oxygen and nutrients.
Removing the drain without the surgeon's order is not appropriate because:
- Premature removal: It could disrupt the healing process and lead to complications such as fluid collection or infection.
- Assessment limitation: Removing the drain would eliminate the ability to monitor ongoing blood loss and could mask potential complications.
A Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied¹. The bulb should be emptied before it is more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing and to maintain the suction
Notifying the surgeon about the blood loss is wrong because it is not an urgent situation unless there are signs of excessive bleeding, such as bright red blood, clots, or a sudden increase in the amount of drainage²³. The surgeon should be notified if the drainage is more than 100 ml in 24 hours or if the color changes from serosanguineous (pink) to sanguineous (red)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is B
Explanation
This statement indicates that the nurse should take steps to ensure effective communication with the client by recommending an interpreter who is the same gender as the client.
This can help to facilitate understanding and comfort during the informed consent process.
Choice A is wrong because nodding alone is not sufficient to indicate understanding.
Choice C is wrong because using medical terminology can be confusing and may not facilitate understanding.
Choice D is wrong because questions should be addressed directly to the client, with the interpreter facilitating communication.
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