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: Ammonia 55 mg/dL is within the normal range of 15 to 60 mg/dL and does not indicate any liver dysfunction or bleeding risk.
Choice B reason: Bilirubin 1.0 mg/dL is within the normal range of 0.3 to 1.2 mg/dL and does not indicate any liver damage or jaundice.
Choice C reason: Aspartate aminotransferase 34 units/L is within the normal range of 10 to 40 units/L and does not indicate any liver inflammation or injury.
Choice D reason: Platelets 60,000/mm³ is below the normal range of 150,000 to 450,000/mm³ and indicates thrombocytopenia, which is a low platelet count that can increase the risk of bleeding during or after the liver biopsy. The nurse should report this value to the provider and monitor the client for signs of bleeding, such as bruising, petechiae, hematuria, or melena.
Correct Answer is A
Explanation
Choice A reason: HbA1c or glycated hemoglobin is a measure of average blood glucose levels over the past 2 to 3 months. A lower HbA1c indicates better glycemic control and a lower risk of diabetes complications. The target HbA1c for most people with diabetes mellitus is less than 7%.
Choice B reason: HbA1c 12.5% is very high and indicates poor glycemic control and a high risk of diabetes complications, such as retinopathy, nephropathy, or neuropathy.
Choice C reason: Fasting blood glucose 100 mg/dL is within the normal range of 70 to 99 mg/dL and indicates normal glucose metabolism, but it does not reflect the long-term control of blood glucose levels over the past 3 months.
Choice D reason: Fasting blood glucose 70 mg/dL is at the lower end of the normal range and may indicate hypoglycemia or low blood glucose levels, which can cause symptoms such as sweating, trembling, hunger, or confusion.
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