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 D
Explanation
Choice A reason: Glucocorticoids are anti-inflammatory drugs that can increase blood glucose levels and worsen diabetes mellitus, which is a risk factor for stroke.
Choice B reason: HbA1c is a measure of average blood glucose levels over the past three months. A higher HbA1c level indicates poor glycemic control and increases the risk for stroke. The target HbA1c level for most people with diabetes mellitus is less than 7 percent.
Choice C reason: Having a high total cholesterol level is a risk factor for stroke, as it can lead to atherosclerosis and plaque formation in the blood vessels. The target total cholesterol level for most people is less than 200 mg/dL.
Choice D reason: Losing excess weight can lower blood pressure, improve blood glucose levels, and reduce inflammation, which are all beneficial for preventing stroke.
Correct Answer is A
Explanation
Choice A reason: BUN or blood urea nitrogen 30 mg/dL is above the normal range of 10 to 20 mg/dL and indicates renal impairment or dehydration, which can be caused by contrast dye used during coronary angiography or blood loss during or after the procedure. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.
Choice B reason: Sinus rhythm 95/min on a cardiac monitor is within the normal range of 60 to 100/min and does not indicate any cardiac arrhythmia or ischemia.
Choice C reason: Respiratory rate 12/min is within the normal range of 12 to 20/min and does not indicate any respiratory distress or hypoxia.
Choice D reason: PTT or partial thromboplastin time 25 seconds is within the normal range of 25 to 35 seconds and does not indicate any bleeding disorder or anticoagulant therapy.
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