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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","C","D","E"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.

A. Wet-to-dry dressings. B. Negative pressure treatment. C. NPWT therapy. D. Hydrocolloid dressings. E. Promoting protein in the diet.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

Wet-to-dry dressings are not typically used for chronic wounds as they can cause tissue damage.

Choice B rationale:

Negative pressure treatment can promote healing by removing excess fluid and promoting blood flow to the wound.

Choice C rationale:

NPWT therapy, or Negative Pressure Wound Therapy, can help heal chronic wounds by removing excess fluid and promoting blood flow.

Choice D rationale:

Hydrocolloid dressings maintain a moist wound environment, which can promote healing.

Choice E rationale:

Protein is essential for wound healing as it is needed for the growth and repair of tissues.

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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

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D","E"]

Explanation

Chronic wounds that are not healing well may benefit from (Select all that apply.)

Correct Answer is ["B","C","D","E"]

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?