NRS 2024: Exam 2 Review
Wound Dehiscence
The partial or total separation of wound layers as a result of excessive stress on wounds that are not healed
How often do you need to eat or drink vitamin C?
- 2-3 times a day - 250-500 mg a day
Metabolic Syndrome and Risk Factors w/ Excessive Abdominal Fat
- A group of conditions that raise your risk of coronary heart disease, diabetes, stroke - Abdominal obesity is the most predominant risk factor for metabolic syndrome
TPN: Total Parental Nutrition
- Administration of nutritional support via the IV route for patients who can't meet their nutritional needs by the oral or enteral routes - Promotes wound and tissue healing and normal metabolic function
For a patient w/ diarrhea:
- Answer call bells immediately - Remove the cause of diarrhea whenever possible - If there is impaction, obtain physician order for rectal examination - Give special care to the region around the anus
Constipating Foods
- Cheese - Lean meat - Eggs - Pasta
Collecting Urinalysis
- Collect urine by having the patient void into a clean bedpan, urinal or receptacle - Avoid contamination w/ feces - If a woman is menstruating - note this on the laboratory slip - Do not place tissue into the urine Aseptic technique - Pour the urine into the container - Label w/ name, DOB, time of collection - package appropriately - Send to lab for examination - Do not leave urine standing at room temperature for a long period before sending to the lab - Clean catch may be used, must be specified, patient voids and discards a small amount of urine, voids into a sterile container
Saturated Fat
- Contains more hydrogen - Solid at room temperature - Increases serum cholesterol levels
What should a nurse do when dehiscence occurs?
- Cover the wound with sterile towels moisturized by sterile 0.9% NaCl solution and notify HCP - Place the patient in the low Fowler's position and cover the exposed abdominal contents - Don't leave the patient alone - Provide reassurance and comfort
Anorexia
- Decreased food intake - Lack of appetite
What will increase basal metabolic rate?
- Fever - Growth - Infection - Emotional tension - Extreme environmental temperatures - Elevated levels of certain hormones
Food with Laxative Effect
- Fruits and vegetables - Bran - Chocolate - Alcohol - Coffee
Stage 3 Pressure Injury
- Full-thickness tissue loss - Subcutaneous may be visible and epibole may occur - Bone, tendon, or muscle is NOT exposed - Slough or eschar may be present but does not obscure the depth of tissue loss - May include undermining and tunneling
Stage 4 Pressure Injury
- Full-thickness tissue loss w/ exposed or palpable bone, cartilage, ligament, tendon, fascia or muscle - Slough or eschar may be present on some part of the wound bed - Epibole, undermining, and/or tunneling occur
TPN - Complications
- Insertion problems - Infection and sepsis - Metabolic alterations - Fluid, electrolyte, and acid-base imbalances - Phlebitis - Hyperlipidemia - Liver and gallbladder disease
Unsaturated Fat
- Less hydrogen - Liquid at room temperature - Lowers serum cholesterol levels
Post Colon Surgery Assessment (1 Day After)
- Measure patient's fluid intake and output - Keep the patient as free of odors as possible; empty the appliance frequently Inspect the patient's stoma regularly - Not the size, which should stabilize within 6-8 weeks - Keep the skin around the stoma site clean and dry - Explain each aspect of care to the patient and hte self-care role - Encourage patient to care for and look at ostomu - Apply ointments or astringent - Use suppositories that contain anesthetics - Use medications as needed
Stool of Breast-Fed Baby
- More frequent - May have curds and mucus - 2-10 stools a day
Risks for Dehiscence
- Obese or malnourished - Smoke tobacco - Use anticoagulants - Have infected wounds - Experience excessive coughing, vomiting, or straining
Gas-Producing Foods
- Onions - Cabbage - Beans - Cauliflower
Why is having a BM on a bedpan difficult?
- Positioning is difficult - The bedpan may spill - Harder to clean the patient - Can be messier
Trans Fat
- Product that occurs when manufacturers partially hydrogenate liquid oils - Considered w/ saturated fats - Raises serum cholesterol
What does TPN do?
- Provides calories - Restores nitrogen balance - Replaces essential fluids, vitamins, electrolytes, minerals, and trace elements
Penrose Drain
- Soft and flexible - Does not have a collection device - Empties into absorptive dressing material - Promotes passive drainage - Not sutured in place - A sterile, large safety pin is attached to the outer portion
Chronic Pain Presentation
- Unrelenting and severe - Consistent w/ or w/o periods of remission or exacerbation - Recurring and contains elements of both chronic and acute pain
Toilet Training
- Voluntary control of the urethral sphincters occurs b/w 18-24 months of age - Usually begins at 2-3 years of age Should not begin until the child is able to: - Hold urine for 2 hours - Communicate the need to void - Control urination until seated on the toilet
Stool of Formula-Fed Baby
- Yellow to brown - Paste like consistency - Stronger odor - May have curds and mucus - 1-2 stools per day
The client is preparing to obtain a clean-catch midstream urine specimen. The following are the steps to complete the diagnostic test:
1. Provide instruction to the client 2. Clean the area surrounding the urinary meatus with the provided cloth 3. Void a small amount into toilet or bedpan 4. Void into the provided collection device 5. Secure the lid on the specimen container 6. Submit collected specimen to the health care professional
Recommended Daily Fluid Intake for Adults
2,000-2,400 mL (8 to 10 8 ox glasses) of fluid daily
Assessing Newborn Urine Output
6-8 wet diapers a day
Fluid Intake
9-13 8 oz cups
Stage 1 Pressure Injury
A defined, localized area of intact skin with nonblanchable erythema
Suspected Deep-Tissue Injury
A persistent, nonblanchable purple or maroon discoloration of intact or nonintact skin, or separation of the epidermis that reveals a dark wound bed or blood-filled blister
Abdominal Assessment
Auscultation comes first b/c palpation will produce false bowel sounds
How is TPN administered?
Can be administered centrally through a central venous access device or peripherally through a short-term IV access in a peripheral vein
Nursing Diagnosis for Urinary Incontinence
Functional incontinence related to impaired mobility
Priority Before Providing Wound Care
Hand hygiene
Hydrogenation
Hydrogen units are added to polyunsaturated fatty acids to prevent them from becoming rancid and to keep them solid at room temperature
Lasix
Loop diuretic that prevents your body from absorbing too much salt
Hydrogenated Fat
Manufactured fats created during hydrogenation
Cutaneous Pain
Pain that involves the skin or subcutaneous tissue
Somatic Pain
Pain that is diffuse or scattered and originates in tendons, bones, blood vessels, and nerves
Visceral Pain
Pain that is poorly localized and originates in body organs in the thorax, cranium, and abdomen
Chronic Pain
Pain that lasts beyond the normal healing period
Phantom Pain
Pain that occurs w/ an amputated leg where receptors and nerves are clearly absent
Stage 2 Pressure Injury
Partial-thickness loss of dermis and presents as a shallow, open ulcer or a ruptured/intact serum-filled blister
Peristalsis in Neurological Conditions
Peristalsis may be impaired with neurological conditions b/c it is controlled by the nervous system
Post-Operative Patient & Voiding
Post-operative urinary retention may present as suprapubic pain or discomfort
What patients are given TPN?
Prescribed for patients who have nonfunctional GI tracts, comatose, high caloric, and nutritional needs due to illness or injury
Largest Organ in the Body
Skin
What physical assessment may indicate protein calorie malnutrition?
Slow healing
Ordering Diagnostic Tests
Start with least invasive
Stress Incontinence
The involuntary loss of urine related to an increase in intra-abdominal pressure
Urge Incontinence
The involuntary loss of urine that occurs soon after feeling an urgent need to void
Female Urethra
Urethral meatus is a slit-like opening below the clitoris and above the vaginal orifice
Unstageable Pressure Injury
When the clinician is unable to visualize the extent of tissue damage due to slough or eschar
A client has developed edema in the lower legs and feet, prompting her health care provider to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate? a. increased output of dilute urine b. increased urine concentration c. a risk of urinary tract infections d. transient incontinence and increased urine production
a
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: a. fluid and electrolyte levels. b. ability to reposition. c. pain level during infusion. d. nausea or vomiting.
a
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? a. Assess the client's wound and vital signs. b. Administer the prescribed analgesic. c. Notify the health care provider of the pain. d. Document the pain and vital signs.
a
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? a. Endorphins b. Serotonin c. Melatonin d. Dopamine
a
A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? a. suprapubic catheter b. indwelling urethral catheter c. intermittent urethral catheter d. straight catheter
a
A health care provider orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition? a. Total parenteral nutrition (TPN) b. Partial or peripheral parenteral nutrition (PPN) c. Percutaneous endoscopic gastrostomy tube (PEG) d. Percutaneous endoscopic jejunostomy tube (PEJ)
a
A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? a. suspected deep tissue injury b. stage II wound c. stage III pressure injury d. unstageable wound
a
A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: a. visceral pain. b. cutaneous pain. c. somatic pain. d. neuropathic pain.
a
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? a. A Penrose drain promotes passive drainage into a dressing. b. A Penrose drain is a closed drainage system that is connected to an electronic suction device. c. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. d. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.
a
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet? a. a diet lacking in fruits and vegetables b. a diet lacking in glucose and water c. a diet lacking in refined grains, seeds, and nuts d. a diet lacking in meat and poultry products
a
A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? a. palpation b. percussion c. auscultation d. inspection
a
A sudden blow to the head results in pain that is transmitted by which type of fibers? a. A-delta b. B-gamma c. C fibers d. D-delta
a
An older adult woman who is incontinent of stool following a cerebrovascular accident. Which nursing concern will the nurse identify for planning care? a. incontinent bowel related to loss of sphincter control, as evidenced by inability to delay the urge to defecate b. diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency c. constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence d. retention of fecal matter related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis
a
In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? a. Infection b. Advanced age c. Prolonged fasting d. Long periods of sleep
a
Most nutritionists recommend having a proper amount of fiber in the diet. In addition to other benefits, how does fiber affect cholesterol? a. increases fecal excretion of cholesterol b. decreases fecal excretion of cholesterol c. facilitates intake and use of trans fat d. raises blood cholesterol levels
a
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a. a client sitting in a chair who slides down b. a client who lifts himself up on the elbows c. a client who lies on wrinkled sheets d. a client who must remain on the back for long periods of time
a
The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus? "Certain vegetables can cause flatus, as they are more difficult to digest." "Parasites in your stool can cause persistent flatus." "Drinking alcoholic beverages can cause flatus." "Flatus is a natural action and the cause is unknown."
a
The nurse is caring for a client who informs the nurse that it is difficult to void when experiencing stress, and asks why this happens. Which response by the nurse is appropriate? a. "Stress causes the muscles to become tense." b. "You require greater privacy to void." c. "You might have a neurologic condition." d. "What medications are you taking?"
a
The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? a. preventing the client from sliding in bed b. pulling the sheets to reposition the client every 2 hours c. improving the client's hydration d. pulling the client up from under the arms
a
The nurse would recognize which client as being particularly susceptible to impaired wound healing? a. an obese woman with a history of type 1 diabetes b. a client whose breast reconstruction surgery required numerous incisions c. a man with a sedentary lifestyle and a long history of cigarette smoking d. A client who is NPO (nothing by mouth) following bowel surgery
a
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a. corticosteroids b. antihypertensive drugs c. potassium supplements d. laxatives
a
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? a. Secure the drain to the client's gown with a safety pin below the level of the wound. b. Tape the drain to the dressing material securely below the level of the wound. c. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. d. Apply an abdominal binder over the entire wound and drain to support the site.
a
Which client would be classified as having chronic pain? a. a client with rheumatoid arthritis b. a client with pneumonia c. a client with controlled hypertension d. a client with the flu
a
Which of the following is considered to be the most potent neuromodulators? a. Endorphins b. Enkephalins c. Efferent d. Afferent
a
The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply. a. How do you rate your pain on a scale of 0 to 10? b. What medication have you taken to relieve the pain? c. When did your pain begin? d. Does anything make the pain worse? e. How would you describe the pain?
a, b, c, d, e
The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. a. an older adult who is confined to bed b. a client with a peripheral vascular disorder c. a client who is obese d. a client who eats a diet high in vitamins A and C e. a client who is taking corticosteroid drugs f. a 10-year-old client with a surgical incision
a, b, c, e
Which assessment data, collected by the nurse, indicates that a client may be assigned the nursing concern of urge urinary incontinence? Select all that apply. a. loses urine when a toilet is not readily available b. urinates 20 times in 24 hours c. wakes up to urinate at night, once weekly d. experiences accidental loss of urine when there is an urgent need to urinate e. can wait up to 30 minutes to urinate after the warning time
a, b, d
A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply. a. The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. b. The client should be asked to defecate into a clean bedpan or toilet bowl, depending on the nature of the study. c. The client should be instructed not to place toilet tissue in the bedpan or specimen container. d. Medical aseptic techniques are always followed. e. Handwashing is performed before and after glove use when handling a stool specimen. f. Generally, 2 inches of formed stool or 20 to 30 mL of liquid stool is sufficient for a stool specimen.
a, c, d, e
A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? a. Decreased heart rate b. Guarding of the chest area c. Increased respiratory rate d. High blood pressure
b
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? a. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." b. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." c. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." d. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."
b
A client who had a recent amputation below the knee tells the nurse about feeling as though the toes are cramping in the missing leg. Which statement will the nurse use to educate the client? a. "Oh, that is all in your mind. Just forget it." b. "That is called phantom pain and it is not unusual." c. "Well, that is really strange. I will notify the health care provider." d. "I think it might be good to refer you to a psychiatrist."
b
A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client? a. "Only take morphine when you have the most severe pain." b. "Increase fluids and high-fiber foods, and use a mild laxative." c. "Administer an enema to yourself every third day." d. "Constipation is nothing to worry about; take your medicine."
b
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? a. Stage I b. Stage II c. Stage III d. Stage IV
b
A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? a. reflex incontinence b. stress incontinence c. urge incontinence d. functional incontinence
b
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which action should the nurse perform with TPN? a. Check vital signs every 8 hours. b. Discard unused TPN every 24 hours. c. Monitor blood glucose levels every 12 hours. d. Change transparent dressings every day.
b
An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? a. Urge b. Stress c. Overflow d. Functional
b
The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? a. stage I b. stage II c. stage III d. stage IV
b
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR? a. an older adult client b. a client who has a fever c. a client who is fasting d. a client who is asleep
b
The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? a. A client suspected to have a perforated peptic ulcer b. A client who has a sprained ankle c. A client with chest pain who is having a myocardial infarction d. A client who has appendicitis
b
The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed? a. The student had the client flex the knees when performing the assessment. b. The student sequenced from auscultation to inspection, and percussion to palpation. c. The student placed the client in supine position with the abdomen exposed. d. The student instructed the client to urinate before beginning the focused assessment.
b
Which medical client is most likely to be experiencing diffuse pain? a. A client who is undergoing diagnostic testing for appendicitis b. A client with shingles affecting her entire torso c. A client who has presented to the emergency department with a stab wound d. A client who has been prescribed antibiotics for the treatment of strep throat
b
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? a. Incontinence after the age of 3 years is not normal. b. Boys may take longer for daytime continence than girls. c. Boys may walk by 1 year and should be continent by 3 years. d. Daytime continence is usually not achieved by boys until age 5.
b
A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? a. urge b. reflect c. stress d. total
c
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? a. acute pain b. chronic pain c. referred pain d. limited pain
c
A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first? a. Release a small amount of urine into the toilet. b. Void normally to empty the bladder. c. Clean each side of the urinary meatus with a separate wipe. d. Catch a sample of urine in the specimen container.
c
A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence? a. stress b. urge c. functional d. total
c
A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan? a. Eat more cabbage and Brussel sprouts to decrease gas and add fiber. b. Drink a soft drink daily to prevent gas and allow fiber to break down. c. Increase fiber slowly over a period of time to prevent gas. d. Include more protein in the diet to increase fiber and decrease gas.
c
A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation? a. high intake of fiber b. constant urges to defecate c. inadequate intake of liquid d. constant physical activity
c
A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include? a. Plans to eat 4 ounces of protein 3 times per day. b. Will includes a pat of butter with eggs for breakfast. c. Plans to eat a snack of fruit twice per day. d. Will include fish one to two times per week.
c
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? a. Infection of the wound b. Herniation of the wound c. Dehiscence of the wound d. Evisceration of the viscera
c
The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? a. blood pressure 130/80 mm Hg b. temperature 99.9°F (37.9°C) c. skin turgor response 5 seconds d. heart rate 90 beats/min
c
The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag? a. Fresh lettuce b. Steamed rice c. Baked beans d. Cooked pasta
c
The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? a. "You will receive medication through this device." b. "Drainage will occur by gravity and capillary action." c. "It provides a way to remove drainage and blood from the surgical wound." d. "The bulb-like system will stay in place permanently after your mastectomy."
c
Which laboratory test is the best indicator of a client in need of TPN? a. Hemoglobin b. Hematocrit c. Serum albumin d. Creatinine
c
A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply. a. elevate the head of the bed 90 degrees four times daily b. provide incontinent care every 2 hours and as needed c. pull the client up in bed as needed d. turn the client every 2 hours when the client is in bed e. encourage the client to take fluids every 2 hours
c, d, e
A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? a. urge b. total c. reflex d. stress
d
A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what? a. Dairy b. Protein c. Unsaturated fats d. Vegetables
d
The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? a. The nurse elevates the foot of the bed. b. The nurse uses a ring cushion to protect reddened areas from additional pressure. c. The nurse increases the amount of time the head of the bed is elevated. d. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.
d
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? a. stage I b. stage II c. stage III d. stage IV
d
The nurse is caring for four older adult clients. Which does the nurse identify at highest risk for cardiometabolic syndrome? a. 50-year old who is of normal weight b. 53-year old with bust larger than hips c. 56-year old with hips larger than bust d. 59-year old with bust, abdomen, and hips of similar proportion
d
The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? a. a newborn b. a client with cardiovascular disease c. an older client with arthritis d. a critical care client
d
The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching? a. Bacon b. Eggs c. Whole milk d. Grapefruit
d
he nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action? a. Don sterile gloves before manipulating the cap of the drain. b. Cleanse the area around the cap with alcohol for 30 seconds before removing it. c. Pin the drain to the client's gown after pulling the tubing taut. d. Recompress the drain before replacing the cap.
d
Gas is another term for
flatulence
A nurse checks a patients Jackson-Pratt (JP) drain following surgery. The nurse explains to the patient that a closed drain speeds healing and facilitates wound draining by
suction
If a patient has urinary retention related to prostate obstruction...
they may need urinary catehterization
Prevention of a wound infection requires diligent care from a nurse. The first and most important step for the nurse to take when emptying the patient's Jackson-Pratt drain is to
wash his or her hands
