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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?

Leave it until the end of the shift.

Remove the drain.

Empty the reservoir.

Notify the surgeon about the blood loss.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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Correct Answer is B

Explanation

Choice A rationale:

An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.

Choice B rationale:

A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.

Choice D rationale:

A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.

A. Stage 1. B. Stage 3. C. Stage 2. D. Stage 4.

Correct Answer is C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is B

Explanation

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

When giving a hot soak treatment, it is most important to:

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A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

A nurse is caring for a client who is at risk for a pressure injury.Which of the following actions should the nurse take?

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

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?