Try Naxlex NCLEX-RN (Free-Trial)

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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Provide brochures about the procedure. B. Complete an incident report. C. Notify the provider. D. Describe the surgery to the client.

Correct Answer is C

Explanation

If a client expresses confusion or lack of understanding about a medical procedure, the nurse should notify the provider so that they can clarify any misunderstandings and ensure that the client is fully informed before giving their consent.
Choice A is wrong because providing brochures about the procedure may not be sufficient to address the client’s confusion or lack of understanding.
Choice B is wrong because completing an incident report is not an appropriate action in this situation.
Choice D is wrong because it is the provider’s responsibility to ensure that the client fully understands the procedure and gives informed consent.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

Correct Answer is C

Explanation

How should the nurse record the net fluid intake for a client who received 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization?

A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220 Ib. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?

A nurse is caring for a client. Exhibits What are the first two actions the nurse should take?

A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?