The nurse is teaching a client who is preparing for surgery. Which teaching about a Jackson-Pratt drain will the nurse include?

"The bulb-like system will stay in place permanently after your surgery."

"You will receive medication through this device."

"This drain minimizes the chance for bacteria to enter the surgical site."

"It provides a way to remove drainage and blood from the surgical wound."

Answer and Explanation

The Correct Answer is D

A. "The bulb-like system will stay in place permanently after your surgery.": A Jackson-Pratt drain is a temporary measure used to collect drainage from a surgical site. It is designed to be removed once the output decreases and the surgical site is healing properly, so it does not remain in place permanently.

B. "You will receive medication through this device.": The Jackson-Pratt drain is specifically for draining fluids from the surgical area and does not administer medication. Medications are typically given through separate methods, such as IV or oral administration.

C. "This drain minimizes the chance for bacteria to enter the surgical site.": While proper drainage can help reduce the risk of complications associated with fluid accumulation, the main purpose of the drain is to facilitate the removal of fluids rather than to directly minimize bacterial entry. Maintaining a clean and sterile technique when handling the drain is essential to prevent infection.

D. "It provides a way to remove drainage and blood from the surgical wound.": This accurately reflects the primary function of the Jackson-Pratt drain. It allows for continuous drainage of excess fluids and blood from the surgical site, helping to prevent complications such as hematomas or seromas and promoting better healing outcomes.

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Correct Answer is B

Explanation

A. The vein appears cordlike: A cordlike appearance of the vein can indicate phlebitis or thrombosis rather than an infection. While this finding may be associated with complications related to an IV catheter, it does not specifically indicate an infection at the insertion site.

B. Purulent drainage is noted from the site: The presence of purulent drainage is a clear sign of infection. Purulent drainage typically indicates the accumulation of pus, which is a result of the body's immune response to infection. This finding aligns with the expectation of an infection at the IV catheter insertion site.

C. The client reports numbness at the site: Numbness is not a common symptom of infection. It may indicate nerve involvement or irritation, which could be related to the placement of the catheter, but it does not directly signify an infection at the insertion site.

D. Skin over the site is sloughing: Sloughing skin may indicate severe tissue damage or necrosis, which could occur in cases of severe infection, but it is not a typical finding in a localized infection at the insertion site. More commonly, an infection would present with redness, warmth, swelling, and possibly purulent drainage.

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI) B. Older adult with a history of dementia admitted for dehydration C. Young adult in the rehabilitative phase after arthroscopic surgery D. Middle-aged woman just diagnosed with terminal lung cancer

Correct Answer is A

Explanation

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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The nurse is teaching a client who is preparing for surgery. Which teaching about a Jackson-Pratt drain will the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Correct Answer is A

Explanation

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