A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation (ORIF). The nurse should understand that the JP drain was placed for which of the following purposes?
To provide a means for medication administration
To prevent fluid from accumulating in the wound
To eliminate the need for wound irrigations
To limit the amount of bleeding from the surgical site
The Correct Answer is B
A. A JP drain is not used for medication administration; its purpose is to remove fluid from the wound area.
B. The primary purpose of a JP drain is to prevent fluid from accumulating in the wound, which helps reduce the risk of infection and promotes healing by allowing continuous drainage of postoperative fluids.
C. While a JP drain helps manage fluid accumulation, it does not eliminate the need for wound irrigations if prescribed as part of the care plan.
D. A JP drain helps manage excess fluid but is not specifically designed to limit bleeding from the surgical site. Bleeding control is generally managed through other measures and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.
B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.
C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.
D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.
Correct Answer is C
Explanation
A. A platelet count of 150,000/mm³ is within the lower end of the normal range and might be monitored but is not the highest priority for intervention in the context of HIV.
B. A positive Western blot test confirms HIV infection but does not provide information on the current immune status or disease progression.
C. A CD4-T-cell count of 180 cells/mm³ indicates significant immunosuppression and is critical as it reflects the progression of HIV and the risk of opportunistic infections. This value is a priority because it directly affects the client’s immune status and potential treatment strategies.
D. A WBC count of 5,000/mm³ is within the normal range and is less critical compared to the CD4-T-cell count, which provides more specific information regarding the client’s HIV status and risk for opportunistic infections.
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