The nurse is instructing nurse externs at an extended care facility. What is the expected range of motion of the hip? (SELECT ALL THAT APPLY)

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.

B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.

C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.

D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.

F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.

A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.

E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.