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 D
Explanation
The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.
Correct Answer is D
Explanation
The correct answer is d. Unplug the pump.
Rationale for Choice A:
- While notifying the biomedical department to fix the pump is important,it is not the immediate priority in this situation.The first step is to ensure patient and staff safety by removing the potential electrical hazard.
- Delaying the removal of the sparking pump could lead to electrical shock,fire,or other serious consequences.
- Biomedical staff can be notified after the immediate safety risk has been addressed.
Rationale for Choice B:
- Obtaining a replacement pump is necessary to continue the client's IV therapy,but it is not the first action the nurse should take.
- The priority is to eliminate the electrical hazard posed by the sparking pump.
- Once the faulty pump is unplugged and safety is ensured,the nurse can then proceed to obtain a replacement pump.
Rationale for Choice C:
- Labeling the pump with a defective equipment sticker is important to prevent others from using it,but it does not address the immediate safety risk.
- The priority is to disconnect the pump from the power source to eliminate the risk of electrical shock or fire.
- Labeling can be done after the pump has been unplugged and the situation has been assessed.
Rationale for Choice D:
- Unplugging the pump is the correct first action because it immediately removes the electrical hazard,preventing potential harm to the patient,staff,or equipment.
- This action prioritizes safety and mitigates the risk of electrical shock,burns,fire,or other serious consequences.
- It is essential to act quickly and decisively in such situations to ensure a safe environment for everyone involved.
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