Nokea
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?
- A. Empty the reservoir.
- B. Notify the surgeon about the drainage.
- C. Remove the drain
- D. Leave it until the end of the shift
Correct Answer: A
Rationale: Emptying the reservoir maintains drainage function and allows monitoring of output; significant changes would then prompt notifying the surgeon.
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What safety factors should be considered when using an Aquathermia pad unit for a patient? (Select all that apply)
- A. Inspecting the plug and cord for cracks or fraying
- B. Securing the pad to the patient
- C. Instructing the patient not to sleep on the pad
- D. Assisting the patient to lie on top of the pad
- E. Using a thermometer to check the temperature of the pad
Correct Answer: A,C
Rationale: A: Ensures electrical safety. C: Prevents burns from prolonged pressure. Lying on the pad (D) increases burn risk.
A nurse is assisting with the care of a client who arrives at the emergency department following an industrial explosion. Upon inspecting the wound on the client's leg, the nurse finds torn skin tissue underneath. Which of the following types of wounds should the nurse report?
- A. Contusion
- B. Laceration
- C. Abrasion
- D. Puncture
Correct Answer: B
Rationale: A laceration is a tear in the skin, fitting the description of torn tissue from an explosion.
A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite the administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
- A. Abdominal pads
- B. Hydrogel
- C. Wet-to-dry
- D. Dry gauze
Correct Answer: B
Rationale: Hydrogel dressings are soothing and reduce pain by maintaining moisture, unlike wet-to-dry, which can stick and hurt.
What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?
- A. Tegaderm or Opsite
- B. Abdominal pads held in place with paper tape
- C. Retention
- D. Montgomery straps
Correct Answer: D
Rationale: Montgomery straps secure dressings with ties, allowing changes without removing tape from the skin.
A nurse is ambulating a patient in the hall a few days after abdominal surgery when the patient says, "I think something just let go." What should be the nurse's initial intervention?
- A. Ask someone to quickly get an abdominal binder.
- B. Seat the patient in a nearby chair.
- C. Instruct the patient to pant to reduce abdominal tension.
- D. Assist the patient into a supine position.
Correct Answer: D
Rationale: Assisting to a supine position reduces strain on the abdominal wound, preventing further dehiscence.