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 D
Explanation
Choice A rationale
Tegaderm or Opsite dressings are transparent and adhesive, allowing for wound inspection without removal, but they do not involve tape that remains in place for multiple changes.
Choice B rationale
Abdominal pads held in place with paper tape would require the tape to be removed and replaced with each dressing change, which can disrupt the skin.
Choice C rationale
The term ‘retention’ is incomplete and does not specify a type of dressing. Retention typically refers to the ability to keep something in place, such as a dressing, but does not imply that the tape remains in place.
Choice D rationale
Montgomery straps are designed with ties that attach to an adhesive base that remains on the skin. This allows the dressing to be changed without removing and reapplying tape, thus preventing skin disruption.
Correct Answer is A
Explanation
Choice A rationale
Moisture from incontinence can compromise skin integrity and create a favorable environment for bacterial growth, increasing the risk of infection and skin breakdown.
Choice B rationale
While a wet bed may be uncomfortable, it does not exert greater pressure that would lead to skin breakdown or infection.
Choice C rationale
Shearing can occur from moving a patient on any surface; however, wet sheets do not inherently increase the likelihood of shearing.
Choice D rationale
Repositioning the patient is necessary for comfort and to prevent pressure ulcers, but it is not a direct cause of skin breakdown or infection due to incontinence.
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