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 nurse can delegate the task of performing a simple dressing change to an assistive personnel.
Delegation is an essential nursing skill that allows a qualified healthcare worker, like an RN, to transfer routine and low-risk duties to nursing assistive personnel.
This frees up the RN’s time to address more pressing matters, including critical patients and tasks.
Choice A is wrong because changing IV tubing is not a task that can be delegated to assistive personnel.
Choice C is wrong because inserting an NG tube is not a task that can be delegated to assistive personnel.
Choice D is wrong because evaluating the healing of an incision is not a task that can be delegated to assistive personnel.
These tasks require the expertise and training of a licensed nurse.
Correct Answer is ["C","D"]
Explanation
The correct answers are:
- c."I need to have a fire escape plan with my family."
- d."I will use the grab bars when getting in and out of the bathtub."
Rationale for each choice:
Choice c:
Having a fire escape plan is crucial for home safety. It ensures that all family members know what to do in the event of a fire, which can save valuable time and lives. Here's a detailed explanation of why a fire escape plan is essential:
- Early Escape:A plan promotes quick evacuation,as everyone understands the escape routes and procedures.
- Reduced Panic:Knowing what to do in a crisis minimizes panic and confusion,allowing for calmer and more efficient actions.
- Accountability:The plan ensures that no one is left behind,especially children,older adults,or individuals with disabilities.
- Firefighter Assistance:It provides vital information to firefighters,aiding their rescue efforts.
- Regular Practice:Regularly practicing the plan familiarizes everyone with their roles and actions,ensuring smoother execution in a real fire.
Choice d:
Grab bars provide stability and support, reducing the risk of falls in bathrooms. Falls are a major safety hazard, especially for older adults, and can lead to serious injuries. Grab bars offer several benefits, including:
- Entering and Exiting:They facilitate safe entry and exit from the bathtub or shower,especially on slippery surfaces.
- Balance Support:They provide support when standing,reducing the likelihood of losing balance.
- Transfer Assistance:They assist individuals with mobility impairments in safely transferring between the bathtub,shower,or toilet.
- Confidence Boost:They offer a sense of security,allowing individuals to feel more confident and independent in the bathroom.
Rationale for incorrect choices:
Choice a:
Setting a hot water heater to 140 degrees Fahrenheit is unsafe. It can cause scalding burns within seconds, especially for children and older adults. The recommended temperature is 120 degrees Fahrenheit to balance safety and energy efficiency.
Choice b:
Taping over frayed electrical cords is a temporary and hazardous fix. It does not address the underlying issue of damaged wiring, which can lead to electrical shocks, fires, or electrocution. Frayed cords should be replaced immediately with new, undamaged ones.
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