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
This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.
Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.
Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.
Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.
They do not indicate a problem with the tube feeding.
Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.
They do not indicate a problem with the tube feeding.
Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.
Correct Answer is A
Explanation
This is the most appropriate action because it respects the client’s right to know and the family’s right to privacy.
It also allows the nurse to collaborate with the family and the healthcare provider to provide the best care for the client.
Choice B is wrong because it violates the client’s autonomy and dignity.
It also prevents the client from making informed decisions about end-of-life care.
Choice C is wrong because it denies the reality of the situation and does not address the client’s concerns.
It also may increase the client’s anxiety and frustration.
Choice D is wrong because it disregards the family’s wishes and cultural values.
It also may cause harm to the client and the family by breaking their trust and creating conflict.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
