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 A
Explanation
After postoperative surgery, chances of infections are very high also discharges, color changes, etc.
So it is important to expose the client’s abdomen to look for changes in appearance.
Choice B is not the answer because determining areas of resonance across the abdomen using a systematic approach is not the first action that should be taken 1.
Choice C is not the answer because using the diaphragm of a stethoscope to listen for bowel sounds is not the first action that should be taken 1.
Choice D is not the answer because performing abdominal palpation by pressing gently with the finger pads is not the first action that should be taken 1.
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.
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