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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 C

Explanation

Choice A rationale:

A laceration is a cut or tear in the skin, not a raised scar.

Choice B rationale:

A contusion is a bruise caused by an impact to the skin, not a raised scar.

Choice C rationale:

A keloid is a thick, raised scar that can develop at the site of an injury or inflammation. It’s more common in people with darker skin tones.

Choice D rationale:

A hematoma is a collection of blood outside of the blood vessels, not a raised scar.

A. there is probably a deeper injury than what appears on the surface. B. he has lain in one position for such a long time that swelling has occurred. C. vessels have dilated and allowed plasma to leak into the wound site. D. an infection is in progress at the wound site.

Correct Answer is C

Explanation

Choice A rationale:

There is probably a deeper injury than what appears on the surface is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice B rationale:

He has lain in one position for such a long time that swelling has occurred is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice C rationale:

Vessels have dilated and allowed plasma to leak into the wound site is the correct answer because this is a normal part of the inflammatory stage of wound healing.

Choice D rationale:

An infection is in progress at the wound site is incorrect because while swelling can be a sign of infection, it is also a normal part of the inflammatory stage of wound healing.

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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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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?