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 ["A","C","D"]
Explanation
E.
Choice A rationale:
Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.
Choice B rationale:
Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.
Choice C rationale:
Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.
Choice D rationale:
Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.
Choice E rationale:
Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.
Correct Answer is D
Explanation
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
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