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 C
Explanation
Choice A rationale
Leaving the old dressing in place and simply covering it with new wet dressings would not address the issue of the dressing being adhered to the wound bed, which could lead to further tissue damage when it is eventually removed.
Choice B rationale
Povidone-iodine is an antiseptic and not typically used to moisten dressings that are stuck to a wound bed, as it may irritate the wound and delay healing.
Choice C rationale
Adding normal saline is the gentlest method to loosen a dressing that is stuck to a wound bed. It helps to rehydrate the dressing and the wound, making it easier to remove without causing additional trauma to the healing tissue.
Choice D rationale
Pulling off the dressing using slow, steady pressure could cause damage to the new tissue forming in the wound bed and should be avoided unless all other methods have failed.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale
Keeping the skin and surrounding tissue clean and dry helps prevent infection, which is crucial for proper wound healing. A clean environment is less likely to harbor bacteria that can cause complications.
Choice B rationale
Proper nutrition, particularly adequate protein and vitamins, provides the necessary building blocks for tissue repair and supports the immune system, which is essential for healing.
Choice C rationale
Resting and minimizing movement of the incisional area help prevent further injury and allow the body’s resources to focus on the healing process.
Choice D rationale
While fluid intake is important, 4000 mL per day may be excessive unless specifically recommended for the patient’s condition. Overhydration can be harmful.
Choice E rationale
Exercise and deep breathing increase blood flow and oxygenation to tissues, which are vital for healing. Oxygen is needed for cellular functions that repair tissue.
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