While assessing the client’s abdomen, you note that the Jackson-Pratt drain’s reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
Empty the reservoir.
Notify the surgeon about the drainage.
Remove the drain
Leave it until the end of the shift
The Correct Answer is A
Choice A:
This is the correct choice. The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half full, the suction pressure is diminished. Thus it is appropriate to empty it and record the amount of drainage you discard.
Choice B:
While it's important to keep the surgeon informed about the patient's condition, in this case, the purpose of the Jackson-Pratt drain is to aspirate drainage, such as excess blood, from the wound. Many factors are involved in determining what an acceptable amount of drainage is; however, excessive blood loss that must be reported is likely to affect the patient's vital signs.
Choice C:
The surgeon determines when to remove the drain, and in most cases, a patent and functioning drain remains in place for a few days.
Choice D:
Leaving the reservoir half full until the end of the shift is not recommended. The suction pressure is diminished when the reservoir is half full, which could affect the drain's effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cleaning directly over the wound with a swab could be harmful as it may disrupt the healing tissue. This method does not follow the principles of medical asepsis, which aim to reduce the risk of infection and promote wound healing.
Choice B rationale
The correct technique for cleaning a wound is to use a swab in a circular motion starting at the center and moving outward. This method helps to prevent recontamination of the clean area and is consistent with aseptic principles, ensuring that any contamination is moved away from the wound, not towards it.
Choice C rationale
Cleaning from the outer abdomen toward the wound could potentially bring contaminants from the less clean abdomen into the sterile area of the wound. This would increase the risk of infection and is not the recommended practice.
Choice D rationale
Swabbing from one side to the other across the wound does not ensure that contaminants are moved away from the wound area. It could spread bacteria across the surface, which is not conducive to proper wound care.
Correct Answer is D
Explanation
Choice A:
es and moisture to digest necrotic tissue. While Dakin's solution can support this process by maintaining a moist wound environment, it does not directly cause autolytic debridement.
Choice B:
Sharp debridement involves the use of a scalpel, scissors, or other sharp instrument to remove dead tissue. Dakin's solution does not perform this function.
Choice C:
Enzymatic debridement involves the use of a topical application of enzymes to break down necrotic tissue. Dakin's solution does not contain these enzymes.
Choice D:
This is the correct choice. Dakin's solution, a sodium hypochlorite-based solution, is used for chemical debridement¹. It can be used to irrigate the wound bed or as the solution for wet-to-moist dressing, effectively cleansing away wound debris and helping create the ideal environment for healing.
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