Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

Allowing the patient to ambulate independently

Administering a sedative to keep the patient calm

Placing the patient in restraints

Implementing a fall prevention protocol

Educating the patient on using the call light system

Answer and Explanation

Correct Answer : D,E

A. Allowing the patient to ambulate independently: This intervention is not appropriate for a patient who scores 30 points on the Morse Fall Scale, which indicates a high risk of falling. The patient should be monitored closely and assisted with ambulation to prevent falls.

B. Administering a sedative to keep the patient calm: While it may be important to keep the patient calm, using sedatives should be approached with caution, as they can increase the risk of falls and impair judgment and coordination. This intervention is not the most appropriate approach to fall prevention.

C. Placing the patient in restraints: Restraints should be used only as a last resort and only when necessary to prevent harm to the patient or others. Using restraints can lead to physical and psychological harm and should not be the primary intervention for fall prevention.

D. Implementing a fall prevention protocol: This is the most appropriate intervention for a patient with a high risk of falling. A fall prevention protocol may include measures such as ensuring a clear path, using assistive devices, and conducting regular assessments of the patient's mobility and safety.

E. Educating the patient on using the call light system: This intervention is important for ensuring the patient feels safe and can call for assistance when needed. Educating the patient on the call light system promotes communication and can help prevent falls by encouraging the patient to seek help when they need to move or ambulate.

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Correct Answer is D

Explanation

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.

A. Prevents scarring by minimizing collagen production B. Relieves pain by numbing the wound area C. Promotes wound healing by increasing blood flow to the wound D. Reduces the risk of infection by creating a sterile environment

Correct Answer is C

Explanation

A. Prevents scarring by minimizing collagen production: Negative pressure wound therapy (NPWT) does not prevent scarring by minimizing collagen production. In fact, NPWT can stimulate collagen production as part of the wound healing process, which can contribute to scar formation.

B. Relieves pain by numbing the wound area: NPWT does not have a numbing effect on the wound area. While it may help promote a more comfortable healing environment, it does not directly relieve pain like local anesthetics or analgesics would.

C. Promotes wound healing by increasing blood flow to the wound: NPWT promotes wound healing by creating a negative pressure environment that helps draw excess fluid away from the wound, reduces edema, and stimulates blood flow to the area. This increased blood flow enhances the delivery of nutrients and oxygen necessary for the healing process, making this option correct.

D. Reduces the risk of infection by creating a sterile environment: While NPWT can help reduce the risk of infection by keeping the wound moist and removing excess exudate, it does not create a completely sterile environment. Proper wound care and dressing changes are still necessary to maintain cleanliness and prevent infection.

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Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

Which of the following is a benefit of negative pressure wound therapy (NPWT) for skin wounds?

Correct Answer is C

Explanation

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