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
When administering a hot soak treatment, it is crucial to soak only the affected area to provide targeted heat therapy. This localized approach helps to increase blood flow, reduce pain, and promote healing in the specific area that requires treatment. Soaking only the affected area also minimizes the risk of overheating and potential burns to other parts of the body.
Choice B rationale
While positioning the patient comfortably is important for any treatment, it is not the most critical aspect of a hot soak treatment. Comfort should always be considered, but the primary goal of the hot soak is to apply heat to the affected area to aid in healing. Therefore, ensuring that only the affected area is soaked takes precedence over general patient comfort in this context.
Choice C rationale
Monitoring the temperature of the water is the most important aspect of a hot soak treatment. The water must be warm enough to be therapeutic but not so hot as to cause burns or discomfort. This ensures the treatment is both safe and effective1.
Choice D rationale
Checking the patient’s skin integrity is important, especially if the patient has a condition that affects skin sensitivity, such as diabetes. However, the immediate concern during a hot soak treatment is to monitor the temperature to prevent injury.
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.
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