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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 A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle. B. Double bag the dressing, label it "biohazard," and send it for decontamination. C. Place the dressing in a biohazardous waste container. D. Discard the dressing in the bedside trash receptacle.

Correct Answer is C

Explanation

Choice A rationale:

Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

Choice B rationale:

Double bagging the dressing, labeling it “biohazard,” and sending it for decontamination is incorrect because it is not the standard procedure for disposing of soiled dressings.

Choice C rationale:

Placing the dressing in a biohazardous waste container is the correct method for disposing of soiled dressings.

Choice D rationale:

Discarding the dressing in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is removing a wound dressing that is saturated with blood and purulent drainage.Which of the following methods should the nurse use when disposing of the soiled dressing?

Correct Answer is C

Explanation

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When preparing to change a sterile dressing over an incision, it is most important to remember to:

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?