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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The first formally educated Black nurse in the United States: Mary Eliza Mahoney graduated from the New England Hospital for Women and Children Training School for Nurses in 1879. She is celebrated as the first African American to complete formal professional nursing education in the U.S., paving the way for diversity in the profession.
B. The first nurse appointed to the Army Nurse Corps: This distinction belongs to Annie W. Goodrich, who helped establish and lead the Army Nurse Corps. It is not associated with Mary Mahoney.
C. The first woman to establish a nursing school in the United States: Florence Nightingale inspired nursing education reforms, and several American pioneers established nursing schools, but Mary Mahoney did not found a school.
D. The founder of the first public health nursing program: Lillian Wald is credited with founding the Henry Street Settlement and initiating public health nursing. Mary Mahoney’s primary contribution was as a trailblazer in professional nursing education.
Correct Answer is B
Explanation
A. Formulate a nursing diagnosis related to impaired gas exchange: Developing a nursing diagnosis is an important step in the planning phase but does not immediately address acute hypoxemia. Immediate intervention to improve oxygenation takes priority.
B. Administer bronchodilator medication: The patient is exhibiting signs of respiratory distress, including tachypnea, hypoxemia, and wheezing. Administering a prescribed bronchodilator can relieve airway constriction, improve oxygenation, and prevent further deterioration. This is the priority action in the acute phase.
C. Evaluate the effectiveness of previous interventions: Evaluation occurs after interventions have been implemented. Since the patient is currently experiencing hypoxemia and respiratory distress, immediate intervention is required before evaluation.
D. Reassess the patient's vital signs in 30 minutes: Waiting 30 minutes delays treatment for a patient with low oxygen saturation and respiratory distress. Immediate assessment and intervention are necessary to prevent hypoxic complications.
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