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
Elastic adhesive tape is not the best option for a patient experiencing skin irritation from tape removal because it may cause further irritation when removed.
Choice B rationale
Karaya paste is primarily used as a skin barrier and adhesive for ostomy appliances, not for securing dressings, especially in cases of skin irritation.
Choice C rationale
Montgomery straps are designed for situations where frequent dressing changes are needed. They allow the dressing to be changed without removing the adhesive straps each time, minimizing skin irritation.
Choice D rationale
Paper tape is less irritating to the skin than elastic adhesive tape, but it still requires removal with each dressing change, which can irritate sensitive skin.
Correct Answer is A
Explanation
Choice A rationale
The High-Fowler’s position, with the client sitting upright at a 90-degree angle, is ideal for abdominal wound irrigation as it reduces the risk of fluid accumulation in the wound area and promotes drainage.
Choice B rationale
The side-lying position is not typically used for abdominal wound irrigation because it can cause pooling of the irrigation solution and does not facilitate easy access to the wound site.
Choice C rationale
The supine position, with the client lying flat on their back, is not suitable for abdominal wound irrigation as it can lead to fluid retention in the wound and does not aid in drainage.
Choice D rationale
The dorsal recumbent position, with the client lying on their back with knees bent, is also not optimal for abdominal wound irrigation due to the potential for fluid to collect in the wound area.
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