A patient who underwent a mastectomy must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, which action should the nurse correct?
Points the device away from herself while opening it.
Refrains from touching the drainage spout with her hand.
Compresses the device in her hand before closing it.
Uses one alcohol wipe to clean both the spout and the plug.
The Correct Answer is D
Choice A rationale
Pointing the device away while opening it is a safe practice to prevent contamination and accidental exposure to bodily fluids.
Choice B rationale
Not touching the drainage spout with the hand is correct as it prevents contamination of the spout, which could lead to infection.
Choice C rationale
Compressing the device before closing it is part of the proper procedure to re-establish the vacuum within the drain, which is necessary for it to function correctly.
Choice D rationale
Using one alcohol wipe to clean both the spout and the plug is incorrect because each should be cleaned with a separate sterile wipe to prevent cross-contamination and maintain sterility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Dakin’s solution is an antiseptic containing sodium hypochlorite, used in chemical debridement to clean wounds and remove dead tissue. It helps to reduce the bacterial load and prepares the wound bed for healing by removing non-viable tissue.
Choice B rationale
While Dakin’s solution aids in the overall healing process by cleaning the wound, it does not directly cause healing. Healing is a complex process involving tissue regeneration and repair, which Dakin’s solution supports indirectly.
Choice C rationale
Phagocytosis is a part of the immune response where cells engulf and digest pathogens and debris. Dakin’s solution does not induce phagocytosis but can reduce the microbial load, making it easier for immune cells to clear the wound.
Choice D rationale
Primary intention refers to the direct healing of a wound with minimal tissue loss, typically through suturing. Dakin’s solution is not used for primary intention but for treating wounds that are already open and require cleaning.
Correct Answer is C
Explanation
Choice A rationale
Numbing the area treated is not a primary physiological effect of moist heat. Moist heat therapy works by increasing the temperature of the skin and underlying tissues, which does not directly numb the area but can lead to an increased pain threshold.
Choice B rationale
Drawing fluid to the site of application is not a physiological effect of moist heat. While moist heat can increase local circulation, it does not specifically draw fluids to the application site³.
Choice C rationale
Dilating the blood vessels is a key physiological effect of moist heat. The increased temperature from the heat application causes vasodilation, which increases blood flow to the area, promoting healing and reducing muscle spasm⁴.
Choice D rationale
Constricting the blood vessels is not a physiological effect of moist heat. In fact, the opposite occurs; moist heat causes vasodilation, not vasoconstriction.
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