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 B

Explanation

A. A client who is 1 day postoperative and has a nursing assistant helping him out of bed: While this client is at risk due to being postoperative, the presence of a nursing assistant provides additional support and assistance, which helps mitigate the risk of falling during this transition.

B. An older adult client who is confused and has urinary frequency: This client is at the greatest risk for a fall. Confusion can impair judgment and coordination, and urinary frequency can lead to hurried movements to the bathroom, increasing the likelihood of falls. Older adults are generally more susceptible to falls due to physiological changes, and the combination of confusion and the need for frequent trips to the bathroom heightens this risk significantly.

C. A client with diabetes mellitus who has a leg ulcer: Although this client may have mobility issues related to the leg ulcer, diabetes does not inherently increase the risk for falls as much as confusion and urinary frequency do. The focus would be on wound care rather than immediate fall risk.

D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days: While this client is at risk due to the leg fracture and the use of crutches, they are likely to have received instruction on proper use of the crutches. If the client is following these instructions, the risk may not be as high as that of the confused older adult.

A. 2,4,3,1 B. 3.4.2.1 C. 4.3.2.1 D. 3.4.1.2

Correct Answer is A

Explanation

1. "The client is deteriorating, and I'm afraid the client is going to arrest." This statement provides a clear and urgent indication of the client's current status, emphasizing the severity of the situation and the immediate concern for potential cardiac arrest. The nurse’s choice of language conveys a sense of urgency that is crucial for the HCP to understand the need for prompt action. In SBAR format, the order is: Situation (2), Background (4), Assessment (3), and Recommendation (1).

2. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask." This statement elaborates on the clinical findings and symptoms, giving the HCP a better understanding of the patient's condition and how it is affecting their overall stability. The details about the patient's physical state, such as skin condition and oxygen saturation, highlight the critical nature of the situation.

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)." This provides the background information, including the patient's vital signs, which is critical for the HCP to evaluate the situation. Clear communication of vital signs establishes a baseline for the HCP to assess the urgency of the clinical scenario and informs potential interventions.

4. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client." This statement summarizes the recommendation, clearly indicating the action the nurse believes should be taken based on the assessment. It conveys the need for immediate evaluation and care in a higher-acuity setting, ensuring that the HCP understands the recommended next steps in the patient’s management.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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