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 C

Explanation

A. The client is attempting to remove the restraint: While this may indicate discomfort or agitation, it does not necessarily warrant loosening the restraint. The nurse should assess the underlying reasons for the client's behavior but may need to keep the restraint in place for safety if the client poses a risk to themselves or others.

B. The client has full range of motion in her wrist: Having full range of motion does not indicate a need to loosen the restraint. The primary concern with restraints is ensuring the client's safety and comfort while monitoring for signs of circulation and proper function.

C. The client's hand is cool and pale: This finding is concerning and indicates potential impaired circulation due to the restraint being too tight. Loosening the restraint is essential in this case to restore circulation and prevent further complications. Coolness and paleness are signs of inadequate blood flow and require immediate action to ensure the client’s safety.

D. The client has a capillary refill of less than 2 seconds: A capillary refill of less than 2 seconds typically indicates good circulation. While monitoring capillary refill is important, this finding alone does not warrant loosening the restraint. The priority is to respond to any indications of compromised circulation.

A. Obtain the provider's prescription renewal every 72 hr. B. Document restraint checks and client status every 2 hr. C. Implement passive range-of-motion exercises. D. Educate the client's family about restraint use. E. Release the restraint and reposition the client every 4 hr.

Correct Answer is ["A","B","C","D"]

Explanation

A. Obtain the provider's prescription renewal every 72 hr.: This is an essential intervention. Restraints must be prescribed by a provider and typically require renewal every 24 to 72 hours, depending on hospital policy and the client's needs. Continuous monitoring and justification for the use of restraints are necessary for ethical and legal compliance.

B. Document restraint checks and client status every 2 hr.: Regular documentation of restraint checks and the client’s status is vital for ensuring safety and monitoring for any potential complications, such as skin breakdown or circulatory issues. Frequent checks help ensure that restraints are being used appropriately and that the client’s needs are being met.

C. Implement passive range-of-motion exercises: Incorporating passive range-of-motion exercises is important for preventing joint stiffness, muscle atrophy, and promoting circulation in an immobile client. These exercises can help maintain some level of mobility and prevent complications associated with prolonged immobility.

D. Educate the client's family about restraint use: Providing education to the family about the rationale for using restraints, their purpose, and the monitoring process is essential for transparency and support. This helps the family understand the situation and the measures being taken to ensure the client’s safety.

E. Release the restraint and reposition the client every 4 hr.: This intervention is not sufficient, as restraints should typically be released more frequently, generally every 1 to 2 hours, to assess the client's condition, provide comfort, and allow for repositioning. Releasing restraints every 4 hours may increase the risk of complications and does not align with best practices for care.

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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

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Correct Answer is C

Explanation

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.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

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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?

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The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

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