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 D

Explanation

A. Stage 2: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss, which may present as an open wound or blister. The presence of black eschar indicates that the skin loss is deeper than what is described in Stage 2.

B. Stage 3: A Stage 3 pressure ulcer involves full-thickness skin loss, which may extend into the subcutaneous tissue but does not involve bone or muscle. However, the presence of black eschar suggests that the wound cannot be accurately assessed because the base is not visible.

C. Stage 1: A Stage 1 pressure ulcer is identified by intact skin with non-blanchable redness. Since there is a broken skin and black eschar in this case, it cannot be classified as Stage 1.

D. Unstageable: A wound is considered unstageable when there is full-thickness skin loss and the base of the wound is covered with necrotic tissue (eschar) or slough, making it impossible to determine the depth and true stage of the ulcer. In this scenario, the black eschar covering the base of the wound prevents accurate staging, so the wound is classified as unstageable.

A. Potassium B. WBC count C. BUN D. RBC count

Correct Answer is B

Explanation

A. Potassium: While potassium levels can be affected by various medical conditions, including kidney function and medications, an elevation in potassium is not specifically indicative of an infection. Instead, potassium levels are more relevant in the context of electrolyte balance and cardiac function.

B. WBC count: An elevated white blood cell (WBC) count is a classic indicator of infection. The body responds to infection by increasing the production of white blood cells to fight off pathogens. A significantly elevated WBC count, especially if accompanied by a shift to the left (an increase in immature neutrophils), suggests an acute inflammatory response and the presence of an infection, making this the correct answer.

C. BUN: Blood urea nitrogen (BUN) levels can increase due to dehydration, renal impairment, or increased protein metabolism but are not a direct indicator of infection. While BUN can provide information about kidney function, it does not specifically indicate the presence of an infection.

D. RBC count: A decrease in red blood cell (RBC) count may indicate anemia or other underlying conditions, but an elevation in RBC count is not associated with infection. RBC count is more relevant to oxygen-carrying capacity and overall blood health rather than the inflammatory response to infection.

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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?

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Naxlex Comprehensive Predictor Exams

A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Correct Answer is B

Explanation

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