While assessing the client’s abdomen, you note that the Jackson-Pratt drain’s reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

Empty the reservoir.

Notify the surgeon about the drainage.

Remove the drain

Leave it until the end of the shift

Answer and Explanation

The Correct Answer is A

Choice A:

This is the correct choice. The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half full, the suction pressure is diminished. Thus it is appropriate to empty it and record the amount of drainage you discard.

Choice B:

While it's important to keep the surgeon informed about the patient's condition, in this case, the purpose of the Jackson-Pratt drain is to aspirate drainage, such as excess blood, from the wound. Many factors are involved in determining what an acceptable amount of drainage is; however, excessive blood loss that must be reported is likely to affect the patient's vital signs.

Choice C:

The surgeon determines when to remove the drain, and in most cases, a patent and functioning drain remains in place for a few days.

Choice D:

Leaving the reservoir half full until the end of the shift is not recommended. The suction pressure is diminished when the reservoir is half full, which could affect the drain's effectiveness.

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Correct Answer is B

Explanation

Choice A rationale
Cleaning directly over the wound with a swab could be harmful as it may disrupt the healing tissue. This method does not follow the principles of medical asepsis, which aim to reduce the risk of infection and promote wound healing.

Choice B rationale
The correct technique for cleaning a wound is to use a swab in a circular motion starting at the center and moving outward. This method helps to prevent recontamination of the clean area and is consistent with aseptic principles, ensuring that any contamination is moved away from the wound, not towards it.

Choice C rationale
Cleaning from the outer abdomen toward the wound could potentially bring contaminants from the less clean abdomen into the sterile area of the wound. This would increase the risk of infection and is not the recommended practice.

Choice D rationale
Swabbing from one side to the other across the wound does not ensure that contaminants are moved away from the wound area. It could spread bacteria across the surface, which is not conducive to proper wound care.

A. Headache. B. Rising pulse and falling blood pressure. C. Lethargy, falling pulse, and rising blood pressure. D. Restlessness, rising pulse, and falling blood pressure.

Correct Answer is D

Explanation

Choice A rationale
A headache is a nonspecific symptom and can be associated with many conditions. It is not typically indicative of internal hemorrhage, which is more likely to present with hemodynamic changes.

Choice B rationale
While a rising pulse is a sign of internal hemorrhage due to the body’s attempt to maintain cardiac output, the blood pressure would typically fall, not rise, as the blood volume decreases.

Choice C rationale
Lethargy and a falling pulse are signs of decreased cardiac output, but in the case of internal hemorrhage, the blood pressure would usually fall, not rise, due to the loss of blood volume.

Choice D rationale
Restlessness, a rising pulse, and falling blood pressure are classic signs of internal hemorrhage. The body responds to blood loss by increasing heart rate to maintain perfusion, but as volume continues to decrease, blood pressure falls.

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While assessing the client’s abdomen, you note that the Jackson-Pratt drain’s reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a dry sterile dressing change for an abdominal wound. In which direction should the nurse use a swab to clean?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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