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
Prepare the client for a central venous line.
Parenteral nutrition (PN) with 20% dextrose and fat emulsions is a hypertonic solution that requires infusion through a central venous line to prevent damage to peripheral veins.
Choice A is wrong because the PN infusion bag should be changed every 24 hours, not every 48 hours.
Choice Cis wrong because blood glucose should be monitored more frequently than once daily when initiating PN therapy.
Choice Dis wrong because PN and fat emulsions can be administered together in a total nutrient admixture (TNA)1.
Correct Answer is A
Explanation
Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain.
Choice B is wrong because taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia.
Choice C is wrong because drinking a cup of hot cocoa before bedtime can interfere with sleep due to its caffeine content.
Choice D is wrong because exercising 1 hr before bedtime can increase alertness and make it more difficult to fall asleep.
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