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 C

Explanation

Choice A rationale:

Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.

Choice B rationale:

Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.

Choice C rationale:

Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.

Choice D rationale:

Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.

A. Full thickness skin loss with visible adipose tissue. B. Full thickness skin loss with visible bone. C. Intact skin with localized erythema. D. Partial-thickness skin loss with red tissue in the wound bed.

Correct Answer is C

Explanation

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Correct Answer is C

Explanation

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

Superficial wounds heal faster when kept:

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: