It is important for the nurse to ensure that the client's post-operative Jackson-Pratt device is patent because its purpose is to:

prevent the collection of fluid in a wound.

assess the degree of healing taking place.

allow healing from the outside to the inside of the wound.

help prevent the entrance of microorganisms.

Answer and Explanation

The Correct Answer is A

A. The JP drain helps prevent excessive accumulation of fluid in the wound by actively draining it away. If fluid were to accumulate excessively, it could impair wound healing and increase the risk of infection.

However, the primary purpose of the JP drain is to remove fluid rather than prevent its collection altogether.

B. The JP drain does not directly assess the degree of healing. Its primary function is to drain fluid from the wound to promote healing by preventing fluid accumulation, which could hinder healing. Assessing the degree of healing typically involves visual inspection of the wound by the healthcare provider rather than relying on the drain.

C. This is not the purpose of the JP drain. Healing generally occurs by the gradual migration of cells and tissues to close the wound, which is an internal process. The JP drain assists in the healing process by preventing complications due to fluid accumulation but does not influence healing from outside to inside.

D. While the JP drain itself does not directly prevent the entrance of microorganisms into the wound, it indirectly contributes to infection prevention by removing excess fluid. Accumulated fluid can provide a medium for bacterial growth, potentially leading to infection. By draining fluid effectively, the JP drain helps maintain a cleaner wound environment, reducing the risk of infection.

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Correct Answer is B

Explanation

B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.

A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.

C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.

D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.

A. pump the cuff up again immediately before releasing it. B. use the client's radial pulse to determine how high to pump up the cuff C. obtain another cuff and take the blood pressure again in 30 minutes. D. release the cuff completely and wait two minutes before retaking the blood pressure.

Correct Answer is D

Explanation

D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.

A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.

B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.

However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.

C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.

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It is important for the nurse to ensure that the client's post-operative Jackson-Pratt device is patent because its purpose is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?

Correct Answer is B

Explanation

The nurse, while obtaining the blood pressure reading of a client, is uncertain when the muffled sounds have ended. What is the nurse's best action at this time?

Correct Answer is D

Explanation

The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Which of these questions, used by the nurse, shows appropriate use of inclusive language?

The nurse takes a client's temperature and gets an unexpected result. Which site would provide the most accurate temperature reading?

A nurse is providing teaching for a client who is placed on a low-sodium diet. Which statement made by the client demonstrates an understanding of dietary teaching? "I will:

The nurse is providing care for an elderly client who has cognitive changes. The nurse recognizes that which statement regarding dementia and delirium is true?

A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)