A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain.
What safety measures should the nurse use to prevent client injury? (Select all that apply).

Advise the client to stay in bed and only get up with assistance.

Place the call bell in reach and respond promptly when activated.

Maintain the bed at working height for convenience when doing post op vital signs.

Keep the lights off to encourage client to rest and recuperate.

Attach the drain to wall suction and keep the tubing pinned to the client’s gown.

Answer and Explanation

Correct Answer : B

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.

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Correct Answer is A

Explanation

This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.

Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.

Giving rescue breaths to a client who has a pulse may cause harm.

Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.

Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.

Chest compressions may cause harm to a client who has a pulse.

A. Oatmeal with a banana, milk, and orange juice. B. Blueberry muffin, cranberry juice, and herbal tea. C. Scrambled egg whites, whole wheat toast, and apple juice. D. Bagel with low fat cream cheese and decaffeinated coffee.

Correct Answer is C

Explanation

This is because furosemide is a diuretic that makes you pee more and lose water and electrolytes such as potassium and sodium.

Therefore, you should avoid foods that are high in sodium or potassium, such as bananas, oranges, cranberries, and bagels with cream cheese.

You should also drink plenty of fluids to prevent dehydration.

Choice A is wrong because oatmeal with a banana, milk, and orange juice contains too much potassium, which can cause irregular heartbeat or muscle weakness when taking furosemide.

Choice B is wrong because blueberry muffins, cranberry juice, and herbal tea contain too much sodium and sugar, which can raise your blood pressure and worsen your heart failure.

Choice D is wrong because a bagel with low-fat cream cheese and decaffeinated coffee contains too much sodium and caffeine, which can cause fluid retention and increase your heart rate.

Normal ranges for potassium are 3.5 to 5.0 mmol/L and for sodium are 135 to 145 mmol/L.

You should monitor your electrolyte levels regularly when taking furosemide.

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A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain. What safety measures should the nurse use to prevent client injury? (Select all that apply).

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain.
What safety measures should the nurse use to prevent client injury? (Select all that apply).