A patient with a Jackson-Pratt drain post-cholecystectomy reports nausea and the absence of drainage. What should be the nurse's first action?
Irrigate the drain with sterile saline.
Notify the healthcare provider immediately.
Increase the patient's oral fluid intake.
Reposition the drain.
The Correct Answer is D
A. Irrigate the drain with sterile saline: Drain irrigation should only be performed with a specific provider order because it risks introducing bacteria into the sterile surgical site or causing tissue damage. The nurse should first attempt less invasive methods to restore function.
B. Notify the healthcare provider immediately: While the provider must be notified of a non-functioning drain and concerning symptoms, the nurse's first action is to assess and attempt to correct the issue to re-establish drainage.
C. Increase the patient's oral fluid intake: Increasing oral fluid intake will not correct a mechanical issue like a clogged or misplaced drain.
D. Reposition the drain: The Jackson-Pratt (JP) drain works via continuous negative pressure (suction). If the reservoir is full, if the tubing is kinked, or if the drain tip is lodged against tissue, drainage will stop. The nurse's first action should be to assess the suction (empty and re-compress the bulb/reservoir) and gently reposition the drain tubing to ensure it's straight, non-kinked, and lying correctly. If this does not restore drainage, the provider should be notified immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Faster healing with minimal scar formation.Primary intention occurs in clean, surgically incised wounds with minimal tissue loss, where the edges are closely approximated (e.g., with sutures). This method allows for rapid epithelialization and healing with a minimal formation of granulation tissue and resulting in a fine, linear scar.
B. Higher risk of infection.Wounds healing by primary intention generally have a lower risk of infection because the edges are closed, preventing microbial entry and reducing the exposed surface area compared to open wounds.
C. Increased granulation tissue formation.Secondary intentionhealing, which occurs in open, contaminated, or tissue-loss wounds (like large pressure injuries or burns), requires the formation of a large amount of granulation tissue to fill the wound bed before epithelialization can occur. Primary intention healing requires very little granulation tissue.
D. Enhanced epidermal migration.While epidermal migration (epithelialization) occurs in both, the overall process is much faster in primary intention because the epithelial cells only need to migrate across a very narrow gap. In secondary intention, the epithelium must migrate across a large surface area once the granulation tissue has filled the defect.
Correct Answer is C
Explanation
A. Use a hot water wash to cleanse the affected area: Hot water can dry out and irritate already compromised skin, increasing the risk of breakdown. Lukewarm water should be used.
B. Cleanse the skin with alcohol-based products: Alcohol is extremely drying and irritating; it strips the skin of its natural protective oils, severely increasing the risk of skin breakdown.
C. Pat the skin dry and apply a moisture barrier cream: Patting the skin avoids friction and shear injury. Applying a moisture barrier cream (e.g., zinc oxide) creates a protective layer against the chemical irritants and moisture from urine/feces, which is the most critical intervention for preventing incontinence-associated dermatitis (IAD).
D. Apply a thick layer of lotion after each incontinence episode: Regular lotion does not provide a robust, long-lasting barrier against irritants. A specialized moisture barrier or skin protectant is required.
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