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: This is incorrect because taking iron supplement with an antacid can reduce its absorption and effectiveness. The client should take iron supplement on an empty stomach or with a source of vitamin C to enhance its absorption.
Choice B: This is incorrect because drinking liquid iron supplement undiluted can stain the teeth and cause irritation to the mouth and throat. The client should dilute liquid iron supplement with water or juice and drink it through a straw.
Choice C: This is correct because increasing fiber intake while taking iron supplement can help prevent constipation, which is a common side effect of iron supplementation. The client should also drink plenty of fluids and exercise regularly to promote bowel movements.
Choice D: This is incorrect because notifying the doctor if stools turn black is not necessary as it is a normal and harmless effect of iron supplementation. The client should only notify the doctor if stools are tarry, bloody, or have a foul odor, which can indicate gastrointestinal bleeding.
Correct Answer is B
Explanation
Choice A: This is incorrect because client status unchanged throughout shift is too vague and does not provide specific details about the client's condition and progress. The nurse should document any changes or interventions that occurred during the shift, such as vital signs, pain level, activity, and drainage.
Choice B: This is correct because abdominal wound dry, without redness is a clear and objective description of the client's wound appearance and healing. The nurse should document any signs of infection or complications, such as redness, swelling, warmth, or purulent drainage.
Choice C: This is incorrect because client received an adequate amount of fluid is too general and does not indicate the exact amount and type of fluid that the client received. The nurse should document the intake and output of the client, including any IV fluids, oral fluids, urine, stool, and drainage.
Choice D: This is incorrect because incision healing well is too subjective and does not reflect the actual assessment of the incision site. The nurse should document the size, color, and condition of the incision, as well as any sutures or staples.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today