A patient has just returned from surgery with a Jackson-Pratt (P) drain in place. Which of the following actions should the nurse prioritize immediately postoperatively?

Clamp the JP drain for one hour before and after meals.

Measure and document the amount and color of drainage.

Elevate the JP drain above the level of the abdomen

Flush the drain with saline every two hours.

Answer and Explanation

The Correct Answer is B

A. Clamp the JP drain for one hour before and after meals: Clamping a Jackson-Pratt drain without specific provider orders can lead to fluid accumulation, increased pressure, and potential complications. Clamping is not a routine immediate postoperative action.

B. Measure and document the amount and color of drainage: Monitoring output and characteristics is critical immediately postoperatively. Accurate documentation helps assess bleeding, infection, or other complications, and provides baseline data for ongoing evaluation of the patient’s recovery.

C. Elevate the JP drain above the level of the abdomen: Jackson-Pratt drains should generally be kept below the level of the surgical site to facilitate gravity drainage. Elevating it above the abdomen can impede drainage and increase risk of fluid accumulation.

D. Flush the drain with saline every two hours: Routine flushing of a JP drain is not indicated and can introduce infection or damage tissue. Only perform irrigation if specifically ordered by the provider.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Place the client in a prone position to improve oxygenation: Prone positioning may improve oxygenation in certain critically ill patients, but it is not the first step for a client with an SpO₂ of 90%. Immediate assessment is necessary before changing position.

B. Notify the provider and prepare for intubation: While persistent hypoxemia may eventually require provider notification, intubation is not indicated without assessment of the patient’s overall respiratory status. Premature escalation can lead to unnecessary interventions.

C. Increase oxygen via nasal cannula to 2 L/min: Administering supplemental oxygen may be appropriate, but initiating treatment without assessing for accuracy of the reading and current signs of respiratory distress could mask underlying issues or result in improper dosing.

D. Verify the reading and assess for signs of respiratory distress: The priority action is to confirm the SpO₂ measurement and evaluate for signs of hypoxia, such as increased work of breathing, cyanosis, or altered mental status. Assessment guides safe, evidence-based interventions and ensures accurate clinical decision-making.

A. Administer the medication as soon as you receive the order to prevent delay in treatment. B. Write down the order immediately and verify it with the prescriber by reading it back. C. Document the order in the electronic health record without verifying it with the prescriber. D. Request a colleague to double-check the verbal order before documenting it

Correct Answer is B

Explanation

A. Administer the medication as soon as you receive the order to prevent delay in treatment: Administering a high-alert medication without verification increases the risk of errors and potential harm. Prompt action should not bypass safety checks.

B. Write down the order immediately and verify it with the prescriber by reading it back: For high-alert medications, the nurse must accurately transcribe the order and perform a read-back verification with the prescriber. This ensures clarity, prevents errors, and aligns with patient safety standards.

C. Document the order in the electronic health record without verifying it with the prescriber: Entering a verbal order without confirmation risks transcription errors and compromises safety, particularly for high-alert medications.

D. Request a colleague to double-check the verbal order before documenting it: Peer verification may help catch errors, but it does not replace the critical step of read-back verification with the prescriber, which is required by safety protocols.

View Question and Answer

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

A patient has just returned from surgery with a Jackson-Pratt (P) drain in place. Which of the following actions should the nurse prioritize immediately postoperatively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's oxygen saturation is measured at 90% on room air. What action should the nurse take first?

Correct Answer is D

Explanation

While receiving a telephone verbal order for a high-alert medication, what is the most critical action the nurse should take?

Correct Answer is B

Explanation

A nurse is documenting a patient's condition using the SOFIER charting method. Which section would be most appropriate to include the patient's reported symptoms of headache and dizziness?

Which of the following scenarios is a direct violation of the HIPAA Privacy Rule?

A nurse is caring for a client with limited mobility due to recent surgery. What is the most appropriate intervention to ensure the client's personal hygiene needs are met?

A nurse is assessing a patient post-abdominal surgery and observes serosanguinous drainage on the dressing. What is the most appropriate initial action for the nurse to take?

In a team nursing model, which of the following actions would best demonstrate effective collaboration among team members to enhance patient care?

In a pediatric setting how should a nurse employ active listening when a child is hesitant to speak about their feelings?

During a family meeting, a nurse notices that the client's spouse appears anxious and quiet. What should the nurse do to demonstrate empathy towards the spouse?

A nurse is asked to delegate a task to an assistive personnel (AP). What should the nurse consider first according to the Nurse Practice Act?