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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

A. Keep the wound dry. B. Help destroy microorganisms in an infected wound. C. Leave the dressing in place for 10 days. D. Occlude air and promote breakdown of necrotic tissue.

Correct Answer is D

Explanation

Choice A rationale:

Hydrocolloid dressings do not keep the wound dry; they maintain a moist environment.

Choice B rationale:

These dressings do not have antimicrobial properties.

Choice C rationale:

While these dressings can be left in place for several days, it is not their major purpose.

Choice D rationale:

Hydrocolloid dressings occlude air and promote autolytic debridement of necrotic tissue.

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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:

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Correct Answer is D

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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: