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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Purulent indicates pus, which is not described here.

Choice B rationale:

Infection usually presents with redness, swelling, and possibly pus, which is not described here.

Choice C rationale:

Debridement is the removal of dead tissue, not indicated by a pinkish-red bumpy area.

Choice D rationale:

A pinkish-red center area that looks bumpy indicates granulation tissue, which is a sign of healing.

A. From the left to the right across the wound. B. From the outer abdomen toward the wound. C. In a circular motion around the wound, circling to the outside. D. Directly over the wound.

Correct Answer is C

Explanation

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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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?