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 assault is the threat of harm or unwanted contact, and battery is the actual physical contact without consent.
If the nurse administers the injection despite the client’s refusal, the nurse is violating the client’s autonomy and right to refuse treatment, and is committing both assault and battery.
Choice A is wrong because malice means having a deliberate intention to harm someone. The nurse may not have malice but may be acting out of ignorance or negligence.
Choice B is wrong because malpractice means a failure to meet a standard of care or conduct that causes injury or damage to a patient.
The nurse may be guilty of malpractice, but this is not the best term to describe the nurse’s action.
Choice C is wrong because negligence means a lack of care or skill that results in harm or injury.
The nurse may be negligent, but this is not the best term to describe the nurse’s action.
Correct Answer is D
Explanation
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
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