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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 A

Explanation

Choice A rationale:

The side-lying position allows gravity to assist in wound irrigation and prevent pooling of the solution.

Choice B rationale:

High-Fowler’s position is not ideal for abdominal wound irrigation as it can lead to pooling of the solution.

Choice C rationale:

In the supine position, the solution can pool around the wound and not effectively irrigate it.

Choice D rationale:

The dorsal recumbent position is not ideal as it can also lead to pooling of the solution.

A. Refrains from touching the drainage spout with the hand. B. Uses one alcohol wipe to clean both the spout and the plug. C. Points the device away from herself while opening it. D. Compresses the device in the hand before closing.

Correct Answer is B

Explanation

Choice A rationale:

Refraining from touching the drainage spout with the hand is a correct practice. This helps to prevent contamination of the drain.

Choice B rationale:

Using one alcohol wipe to clean both the spout and the plug is incorrect. Each part should be cleaned with a separate alcohol wipe to prevent cross-contamination.

Choice C rationale:

Pointing the device away from oneself while opening it is a correct practice. This helps to prevent accidental exposure to the drainage fluid.

Choice D rationale:

Compressing the device in the hand before closing is a correct practice. This helps to maintain the suction in the drain.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?