What color and consistency would you expect serous drainage from a Jackson-Pratt (JP) drain to have?

Bright red, bloody fluid

Thick, green fluid

Clear, watery fluid with a pale yellow tint

Milky, white fluid

Answer and Explanation

The Correct Answer is C

A. Bright red, bloody fluid: Bright red fluid indicates fresh blood, which is typically seen in the initial drainage from a surgical site or in cases of active bleeding. This type of drainage is not characteristic of serous fluid and may suggest a complication that requires further assessment.

B. Thick, green fluid: Thick, green fluid often indicates the presence of infection or pus, which would be classified as purulent drainage rather than serous. Serous drainage should not have a thick consistency or a green color, as this would suggest an inflammatory process or infection.

C. Clear, watery fluid with a pale yellow tint: This describes serous drainage, which is typically light in color and has a watery consistency. Serous fluid is a normal finding in the early stages of wound healing, as it contains plasma and does not indicate infection or excessive bleeding.

D. Milky, white fluid: Milky or cloudy fluid can indicate the presence of chyle (lymphatic fluid) or infection, which is not characteristic of serous drainage. Serous fluid should not appear milky, as this would suggest a different underlying issue that may need to be investigated further.

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Correct Answer is B

Explanation

A. To increase blood flow to the wound site: While debridement may indirectly help improve blood flow by removing barriers to healing, its primary purpose is not to increase blood flow. Increased blood flow is a result of improved wound bed conditions rather than the main goal of the procedure.

B. To remove necrotic tissue to promote healing: The primary purpose of wound debridement is to remove necrotic (dead) or devitalized tissue from the wound bed. This process promotes healing by creating a clean wound environment, facilitating granulation tissue formation, and reducing the risk of infection, making this option the most accurate.

C. To apply antibiotics directly to the wound: While antibiotics may be part of the overall wound care plan, debridement itself is not intended for the direct application of antibiotics. The focus is on removing non-viable tissue rather than applying medications during the procedure.

D. To prevent scar formation: While proper wound care, including debridement, can help improve healing outcomes and potentially minimize scarring, the primary aim of debridement is not to prevent scars. Scarring is influenced by multiple factors, including the type of wound, depth, and individual healing responses.

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI) B. Older adult with a history of dementia admitted for dehydration C. Young adult in the rehabilitative phase after arthroscopic surgery D. Middle-aged woman just diagnosed with terminal lung cancer

Correct Answer is A

Explanation

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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What color and consistency would you expect serous drainage from a Jackson-Pratt (JP) drain to have?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In a clinical setting, a patient with a chronic wound is scheduled for debridement. Which of the following is the primary purpose of wound debridement?

Correct Answer is B

Explanation

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Correct Answer is A

Explanation

The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first?