The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes serosanguineous drainage present in the drain. Which is the nurse's priority action?
a. Gently milk the drain tubing.
b. Notify the surgeon immediately.
c. Document the finding in the client's chart.
d. Irrigate the drain with sterile normal sa-line.
C
Drainage from the JP drain initially appears serosanguineous in color. The drainage will appear bile-colored within 24 hours. The nurse does not need to notify the surgeon, milk the tubing, or irrigate the drain because this is an expected finding.
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The nurse giving discharge instructions to the patient who is severely allergic to insect stings would caution the patient to:
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Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
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MC Among the suggestions for health system reform from the Institute of Medicine's Committee on Quality of Health Care in America is
A. Individualizing care based on client needs and values. B. Reducing waits and delays in services provided. C. Providing evidence-based services to those who can benefit from them and withholding services from those who cannot benefit from them. D. Avoiding waste of resources.
A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:
A) infection. B) herniation. C) dehiscence. D) evisceration.