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 D
Explanation
This is because the prescribed dose is 1 tablespoon, which is equivalent to 15 ml. Therefore, to get the amount of milliliters for each dose, you need to multiply 15 ml by 2, which gives you 30 ml.
Choice A is wrong because 10 ml is less than 1 tablespoon.
Choice B is wrong because 5 ml is equal to 1 teaspoon, which is one-third of a tablespoon.
Choice C is wrong because 15 ml is equal to 1 tablespoon, which is half of the prescribed dose.
Correct Answer is B
Explanation
“Tell me what your pain feels like.” This question allows the nurse to assess the quality of pain, which is one of the characteristics of pain that can help determine its cause and treatment. Quality of pain refers to how the client describes the pain, such as sharp, dull, burning, throbbing, etc.
Choice A is wrong because it assesses the intensity of pain, not the quality. Intensity of pain is how much the pain hurts on a scale of 0 to 10 or using other methods.
Choice C is wrong because it assesses the precipitating factors of pain, not the quality. Precipitating factors are events or activities that trigger or worsen the pain.
Choice D is wrong because it assumes a specific quality of pain without asking the client. The nurse should not suggest words to describe the pain, but rather let the client use their own words.
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