A patient who underwent a mastectomy must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, which action should the nurse correct?
Points the device away from herself while opening it.
Refrains from touching the drainage spout with her hand.
Compresses the device in her hand before closing it.
Uses one alcohol wipe to clean both the spout and the plug.
The Correct Answer is D
Choice A rationale
Pointing the device away while opening it is a safe practice to prevent contamination and accidental exposure to bodily fluids.
Choice B rationale
Not touching the drainage spout with the hand is correct as it prevents contamination of the spout, which could lead to infection.
Choice C rationale
Compressing the device before closing it is part of the proper procedure to re-establish the vacuum within the drain, which is necessary for it to function correctly.
Choice D rationale
Using one alcohol wipe to clean both the spout and the plug is incorrect because each should be cleaned with a separate sterile wipe to prevent cross-contamination and maintain sterility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hydrocolloid dressings are used for autolytic debridement, which is a gentle method that allows the body’s enzymes to naturally break down necrotic tissue. This type of dressing maintains a moist wound environment that facilitates the breakdown of dead tissue without damaging healthy tissue.
Choice B rationale
Sharp debridement involves the physical removal of dead tissue using sterile instruments and is not typically performed with a hydrocolloid dressing.
Choice C rationale
Enzymatic debridement uses chemical enzymes to break down necrotic tissue. While enzymatic debridement is a chemical process, it is not synonymous with the use of hydrocolloid dressings.
Choice D rationale
Chemical debridement refers to the use of chemical agents to dissolve necrotic tissue. Hydrocolloid dressings do not contain these agents and are not used for chemical debridement.
Correct Answer is C
Explanation
Choice A rationale
Sanguineous drainage is indicative of active bleeding and is typically bright red due to the presence of red blood cells. This type of drainage is not yellow-red and is not consistent with the description provided.
Choice B rationale
Serous drainage is clear and watery, and it is the fluid that is seen in blisters. It does not have a yellow-red color, so it does not match the description of the drainage observed.
Choice C rationale
Serosanguineous drainage is a mixture of serous and sanguineous drainage. It is typically light red or pink in color, which corresponds with the moist yellow-red stain described, indicating the presence of both plasma and red blood cells.
Choice D rationale
Purulent drainage is thick and opaque, usually yellow, green, or brown, and is associated with infection. The description of a yellow-red stain does not suggest that the drainage is purulent.
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