A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the following actions should the nurse take?
Maintain the client on bed rest.
Decrease the client's fluid intake.
Apply cold compresses to the site.
Place the right leg in a dependent position.
The Correct Answer is D
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.
Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.
Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.
Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.
Correct Answer is A
Explanation
Choice A reason: Changed mental status, such as confusion, agitation, or delirium, can be a sign of a bladder infection in older adults, as they may not have the typical symptoms of dysuria, frequency, or urgency.
Choice B reason: WBC count 9,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate an infection.
Choice C reason: Diminished reflexes are not related to a bladder infection and may be due to aging, neurological disorders, or medication side effects.
Choice D reason: Temperature 37.3°C (99.1°F) is slightly elevated but not indicative of a bladder infection. Older adults may have lower baseline temperatures and may not develop fever in response to an infection.
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