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
Vacuum-assisted closure (VAC) therapy aids in wound healing primarily by applying negative pressure to draw the wound edges together. This not only helps reduce the size of the wound but also promotes blood flow to the area, which can accelerate healing.
Choice B rationale
While VAC therapy does support the underlying structures of the wound, its primary function is not to strengthen the wall of the wound. The negative pressure assists in removing excess fluid and reducing edema, which indirectly supports the wound structure.
Choice C rationale
VAC therapy does have an impact on bacterial levels within the wound by helping to remove infectious materials. However, its main purpose is not to interrupt bacteria proliferation; this is more directly achieved through antibiotic therapy and proper wound care techniques.
Choice D rationale
While VAC does create a cover over the wound, its main purpose is to apply negative pressure to the wound area. This negative pressure helps to draw the wound edges together, promotes the removal of exudate and potentially infectious material, and stimulates the growth of new tissue, which aids in the healing process12. The occlusive cover is part of the system that allows the negative pressure to be maintained, but it is the negative pressure itself, not the cover, that provides the therapeutic benefit.
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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