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 C
Explanation
Choice A reason: Eliminating egg whites from the diet is not necessary, as they are a good source of protein and do not contain any fat or cholesterol. The client should limit or avoid egg yolks, which are high in cholesterol and saturated fat.
Choice B reason: Using coconut oil when preparing food is not advisable, as it is a source of saturated fat that can raise blood cholesterol levels and increase the risk of atherosclerosis and heart disease. The client should use unsaturated fats, such as olive oil or canola oil, which can lower blood cholesterol levels and improve heart health.
Choice C reason: Eating fish three times a week is a good practice, as fish are rich in omega-3 fatty acids that can reduce inflammation, lower blood pressure, and prevent blood clots that can cause heart attacks or strokes. The client should choose oily fish, such as salmon, tuna, or mackerel, which have higher amounts of omega-3 fatty acids.
Choice D reason: Including 2 percent milk in the diet is not recommended, as it contains more fat and calories than skim or 1 percent milk. The client should choose low-fat or fat-free dairy products, such as yogurt, cheese, or milk, which can provide calcium and protein without excess fat.
Correct Answer is B
Explanation
Choice A reason: Staying nearby can provide comfort and support is not an appropriate response, as it does not acknowledge or validate the partner's feelings of grief and loss. The nurse should listen empathetically and encourage the partner to express their emotions.
Choice B reason: I can understand your feelings of sadness is an appropriate response, as it shows empathy and compassion for the partner's situation and allows them to feel heard and understood.
Choice C reason: I will be positive and optimistic for you is not an appropriate response, as it implies that the partner's feelings are negative or inappropriate and that they need to be changed or fixed. The nurse should respect and accept the partner's feelings without judging or minimizing them.
Choice D reason: You should try to be strong for him is not an appropriate response, as it places pressure and expectations on the partner and discourages them from showing their true feelings. The nurse should support and empower the partner without imposing their own values or beliefs.
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