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 D

Explanation

D. Counting the radial pulse for 30 seconds and then multiplying the count by two gives an estimate of the client's heart rate per minute (bpm). This method is efficient and commonly used in clinical practice, especially if the client's pulse is regular.

A. Counting the radial pulse for two minutes is unnecessarily long and not standard practice. Typically, the radial pulse is counted for either 30 seconds or 60 seconds (one minute) to determine the client's heart rate. Multiplying the count by two for a 30-second count or directly using the count for a 60- second count provides the client's beats per minute (bpm).

B. The radial pulse is assessed by palpating the radial artery on the thumb side (or lateral side) of the client's wrist. The nurse places the index and middle fingers gently over the radial artery and applies light pressure to feel the pulse rhythm and rate.

C. Using the thumb to count the pulse is not recommended because the thumb has its own pulse, which could interfere with accurately assessing the client's radial pulse.

A. Bronchovesicular B. Vesicular C. Bronchial D. Crackles

Correct Answer is B

Explanation

B. Heard over most of the lung fields, except for the major bronchi and the trachea.

Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.

A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.

C. Heard over the trachea and larynx.

Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.

D. Crackles are abnormal breath sounds that can be fine or coarse.

Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.

Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.

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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 prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:

Correct Answer is D

Explanation

When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?

Correct Answer is B

Explanation

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