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
Explanation
Choice A rationale:
Dakin’s solution is used for chemical debridement, which involves the use of a chemical, such as Dakin’s solution, to break down and remove dead tissue.
Choice B rationale:
Primary intention is a term used to describe the healing of a clean wound without tissue loss. Dakin’s solution does not directly contribute to this process.
Choice C rationale:
While Dakin’s solution can aid in the healing process by preventing and treating infections, it does not directly cause healing.
Choice D rationale:
Phagocytosis is a process carried out by certain cells in the body to engulf and destroy pathogens or debris. Dakin’s solution does not perform this function.
Correct Answer is A
Explanation
Choice A rationale:
An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.
Choice B rationale:
A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.
Choice D rationale:
A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.
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