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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.
Choice B rationale:
It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.
Choice C rationale:
Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.
Choice D rationale:
Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.
Correct Answer is ["B","C","D"]
Explanation
D.
Choice A rationale:
A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.
Choice B rationale:
Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.
Choice C rationale:
Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.
Choice D rationale:
Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.
Choice E rationale:
A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.
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