What color and consistency would you expect serous drainage from a Jackson-Pratt (JP) drain to have?

Bright red, bloody fluid

Thick, green fluid

Clear, watery fluid with a pale yellow tint

Milky, white fluid

Answer and Explanation

The Correct Answer is C

A. Bright red, bloody fluid: Bright red fluid indicates fresh blood, which is typically seen in the initial drainage from a surgical site or in cases of active bleeding. This type of drainage is not characteristic of serous fluid and may suggest a complication that requires further assessment.

B. Thick, green fluid: Thick, green fluid often indicates the presence of infection or pus, which would be classified as purulent drainage rather than serous. Serous drainage should not have a thick consistency or a green color, as this would suggest an inflammatory process or infection.

C. Clear, watery fluid with a pale yellow tint: This describes serous drainage, which is typically light in color and has a watery consistency. Serous fluid is a normal finding in the early stages of wound healing, as it contains plasma and does not indicate infection or excessive bleeding.

D. Milky, white fluid: Milky or cloudy fluid can indicate the presence of chyle (lymphatic fluid) or infection, which is not characteristic of serous drainage. Serous fluid should not appear milky, as this would suggest a different underlying issue that may need to be investigated further.

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Correct Answer is A

Explanation

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.

A. Mask B. Face shield C. Gown D. Gloves

Correct Answer is D

Explanation

A. Mask: The mask is removed after the gloves to prevent any contaminants from the gloves from touching the face, particularly around the mouth and nose area. Removing the mask first could increase the risk of exposure to pathogens.

B. Face shield: Similar to the mask, the face shield is also removed after the gloves. This helps to avoid contamination from the gloves to the face. Removing the face shield before the gloves could pose a risk of exposure to infectious materials.

C. Gown: The gown is typically removed after the gloves to ensure that any contaminants on the gloves do not come into contact with the nurse's skin or clothing. Removing the gown before the gloves can also lead to cross-contamination.

D. Gloves: Gloves should be the first item removed when taking off personal protective equipment. This is because gloves are the most likely to be contaminated with infectious materials. Removing them first minimizes the risk of transferring pathogens to other areas of the body or clothing during the process of doffing PPE. After removing the gloves, the nurse can safely proceed to remove other items, such as the gown, face shield, and mask, following proper protocols.

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What color and consistency would you expect serous drainage from a Jackson-Pratt (JP) drain to have?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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