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?
Leave it until the end of the shift.
Remove the drain.
Empty the reservoir.
Notify the surgeon about the blood loss.
The Correct Answer is C
Choice A rationale:
Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.
Choice B rationale:
Removing the drain is not within the nurse’s scope of practice and could lead to complications.
Choice C rationale:
Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.
Choice D rationale:
Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.
Choice B rationale:
Placing a discard bag close to the wound can increase the risk of infection.
Choice C rationale:
Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.
Choice D rationale:
Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.
Correct Answer is C
Explanation
Choice A rationale:
An abrasion is a superficial injury to the skin caused by scraping or rubbing, which does not match the description of a pooling of blood under unbroken skin.
Choice B rationale:
An avulsion is a wound where a chunk of tissue is torn away, which does not match the description of a pooling of blood under unbroken skin.
Choice C rationale:
A hematoma is a pooling of blood outside of blood vessels, typically caused by trauma. It matches the description of a pooling of blood under unbroken skin.
Choice D rationale:
A laceration is a deep cut or tear in the skin, which does not match the description of a pooling of blood under unbroken skin.
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