A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation (ORIF). The nurse should understand that the JP drain was placed for which of the following purposes?
To provide a means for medication administration
To prevent fluid from accumulating in the wound
To eliminate the need for wound irrigations
To limit the amount of bleeding from the surgical site
The Correct Answer is B
A. A JP drain is not used for medication administration; its purpose is to remove fluid from the wound area.
B. The primary purpose of a JP drain is to prevent fluid from accumulating in the wound, which helps reduce the risk of infection and promotes healing by allowing continuous drainage of postoperative fluids.
C. While a JP drain helps manage fluid accumulation, it does not eliminate the need for wound irrigations if prescribed as part of the care plan.
D. A JP drain helps manage excess fluid but is not specifically designed to limit bleeding from the surgical site. Bleeding control is generally managed through other measures and monitoring.
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Related Questions
Correct Answer is C
Explanation
A. While assessing perianal skin integrity is important for managing ulcerative colitis, it is not the immediate priority. Addressing electrolyte imbalances is crucial for stabilizing the client's condition first.
B. Emotional concerns are important but are secondary to addressing immediate physical health needs, such as electrolyte imbalances, which can be life-threatening if not managed promptly.
C. Reviewing electrolyte values is critical in an acute exacerbation of ulcerative colitis because diarrhea and fluid loss can lead to significant electrolyte imbalances, which need to be corrected to prevent complications.
D. Obtaining a dietary history is relevant for overall management but is not the immediate priority. Addressing electrolyte imbalances and hydration status is more urgent in acute exacerbations.
Correct Answer is A
Explanation
A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.
B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.
C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.
D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.
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