A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the following actions should the nurse take?
Maintain the client on bed rest.
Decrease the client's fluid intake.
Apply cold compresses to the site.
Place the right leg in a dependent position.
The Correct Answer is D
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Isoniazid is an antitubercular drug that can cause urine to turn dark yellow or brown, not red-orange.
Choice B reason: Metoprolol is a beta-blocker that can cause urine to turn blue-green, not red-orange.
Choice C reason: Rifampin is an antitubercular drug that can cause urine to turn red-orange, as well as other body fluids such as saliva, sweat, and tears.
Choice D reason: Furosemide is a diuretic that can cause urine to become more concentrated and darker in color, but not red-orange.
Correct Answer is A
Explanation
Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.
Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.
Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.
Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.
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