A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.
As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:
Refrains from touching the drainage spout with the hand.
Uses one alcohol wipe to clean both the spout and the plug.
Points the device away from herself while opening it.
Compresses the device in the hand before closing.
The Correct Answer is B
Choice A rationale:
Refraining from touching the drainage spout with the hand is a correct practice. This helps to prevent contamination of the drain.
Choice B rationale:
Using one alcohol wipe to clean both the spout and the plug is incorrect. Each part should be cleaned with a separate alcohol wipe to prevent cross-contamination.
Choice C rationale:
Pointing the device away from oneself while opening it is a correct practice. This helps to prevent accidental exposure to the drainage fluid.
Choice D rationale:
Compressing the device in the hand before closing is a correct practice. This helps to maintain the suction in the drain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.
Choice B rationale:
It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.
Choice C rationale:
Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.
Choice D rationale:
Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.
Correct Answer is C
Explanation
Choice A rationale:
A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.
Choice B rationale:
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.
Choice C rationale:
Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.
Choice D rationale:
Stage 3 pressure injuries involve full-thickness skin loss.
Choice E rationale:
Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.
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