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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Cataracts are a condition where the lens of the eye becomes opaque, causing impaired vision. Blurred or cloudy vision is a common symptom of cataracts.
Some possible explanations for the other choices are:
Choice B. Burning sensation in the eye. This is not a typical symptom of cataracts, but it could indicate an infection, allergy, or dry eye syndrome.
Choice C. Inability to produce tears. This is also not a typical symptom of cataracts, but it could indicate a problem with the lacrimal glands or ducts that produce and drain tears.
Choice D. A swollen lacrimal gland. This is not a symptom of cataracts, but it could indicate an inflammation or infection of the lacrimal gland, which is located near the upper eyelid.
Normal ranges for visual acuity are 20/20 for normal vision and 20/40 for mild impairment. Visual acuity can be measured using a Snellen chart or other methods.
Correct Answer is D
Explanation
This is because the nurse should always follow the ABC (airway, breathing, circulation) priority when dealing with a client who suddenly slumps over. The nurse should check if the client is conscious and breathing before calling for help or moving the client.
Choice A is wrong because calling the rapid response team should not be done before assessing the client’s condition and ensuring a patent airway.
Choice B is wrong because moving the client to the bed may cause further harm or aspiration if the client has food in the mouth or airway.
Choice C is wrong because calling the primary care provider is not a priority action in this situation. The nurse should first assess and stabilize the client before notifying the provider.
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