After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

Correct Answer: D

Rationale: In the context of postoperative care following an abdominal resection for colon cancer, the Jackson-Pratt drain serves the specific purpose of preventing the accumulation of drainage in the wound. This drain helps to remove excess fluid, blood, and potential contaminants from the surgical site, thereby promoting proper wound healing and reducing the risk of complications such as infection, seroma formation, or delayed wound healing. Option A, irrigating the incision with saline, is not the primary function of a Jackson-Pratt drain. While wound irrigation is a common nursing intervention, the drain itself is not used for this purpose. Option B, preventing bacterial infection of the incision, is indirectly related to the drain's function. By removing excess fluid that may harbor bacteria, the drain can help reduce the risk of infection. However, the primary role of the drain is to prevent fluid accumulation. Option C, measuring the amount of fluid lost after surgery, is not the main purpose of a Jackson-Pratt drain. While the amount of drainage can provide valuable information about a patient's postoperative status, the drain's primary function is to prevent fluid buildup. Educationally, understanding the rationale behind the use of Jackson-Pratt drains postoperatively is crucial for nurses caring for patients undergoing abdominal surgeries. It is vital to grasp the specific purposes of various types of drains to provide effective and evidence-based care, prevent complications, and promote optimal patient outcomes.

Correct Answer: B

Rationale: In the context of a patient with a possible bowel obstruction like Claire, the priority intervention is to measure abdominal girth (Option B). This is crucial because an increasing abdominal girth can indicate abdominal distension, a common sign of bowel obstruction. Measuring the abdominal girth helps in monitoring for signs of worsening obstruction, such as increased pressure on the bowel walls, which can lead to complications like perforation. Obtaining daily weights (Option A) may be important for fluid balance assessment but is not the priority in this situation where the focus is on identifying and managing a potential complication like bowel obstruction. Similarly, keeping strict intake and output (Option C) and encouraging increased fluids (Option D) are important aspects of nursing care but do not take precedence over assessing for signs of a worsening condition like bowel obstruction. In an educational context, understanding the priority interventions in specific clinical scenarios is vital for nurses to provide timely and effective care to patients. Recognizing the significance of assessing abdominal girth in a patient with a possible bowel obstruction highlights the importance of clinical judgment and critical thinking in nursing practice.

Correct Answer: C

Rationale: In this scenario, the preferred method of feeding for a patient with the inability to swallow foods but with a functioning GI tract is Nasogastric (NG) feeding, which is option C. NG feeding involves the insertion of a tube through the nose into the stomach, allowing for the delivery of liquid nutrition directly into the gastrointestinal system. The correct answer is NG feeding because it bypasses the oral route while still utilizing the patient's functional GI tract for absorption of nutrients. This method helps maintain the integrity of the GI system and prevents complications associated with total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN), which are options A and B, respectively. TPN and PPN are reserved for patients who cannot tolerate enteral feeding or have non-functional GI tracts. Oral liquid supplements (option D) are not suitable for this patient as they cannot swallow foods effectively. From an educational perspective, understanding the rationale behind choosing NG feeding in this situation highlights the importance of considering the most appropriate and least invasive method of providing nutrition to patients with specific feeding requirements based on their clinical condition. It also emphasizes the significance of maintaining GI function whenever possible to support overall patient well-being and prevent complications associated with alternative feeding methods.

Correct Answer: A

Rationale: In the context of medical-surgical nursing and gastrointestinal system assessment, the correct priority when a patient complains of abdominal pain is option A) Auscultate to determine changes in bowel sounds. The rationale behind this choice is that changes in bowel sounds can provide crucial information about the functioning of the gastrointestinal tract. Auscultation allows the nurse to assess for the presence or absence of bowel sounds, which can indicate issues such as obstruction, peritonitis, or ileus. Absent bowel sounds may suggest a serious condition requiring immediate intervention. The other options are not the priority because: - Option B) Observing the contour of the abdomen can provide information about distention or abnormal masses, but assessing bowel sounds is more indicative of immediate gastrointestinal function. - Option C) Palpating the abdomen for a mass should only be done after assessing bowel sounds, as palpation can exacerbate pain or discomfort in certain conditions. - Option D) Percussing the abdomen for fluid is not the initial priority when a patient presents with abdominal pain, as auscultation provides more specific information related to gastrointestinal function. Educationally, understanding the rationale behind prioritizing auscultation in assessing abdominal pain reinforces the importance of systematic and evidence-based nursing assessment. It highlights the need for nurses to prioritize assessments based on the urgency of the situation and the potential impact on patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Lower the height of the enema container. Intestinal cramps during enema administration can indicate that the solution is flowing too quickly or with too much force into the intestines. Lowering the height of the enema container will reduce the rate of flow, alleviating the cramps and making the procedure more tolerable for the patient. Discontinuing the procedure (Option A) without addressing the cause of cramps may not be necessary if the issue can be resolved by adjusting the flow rate. Completing the procedure as quickly as possible (Option C) may exacerbate the cramps and cause discomfort for the patient. Continuing administration without adjustments (Option D) can lead to increased discomfort and potential harm to the patient. Educationally, understanding the importance of monitoring patient responses during procedures like enema administration is crucial for nurses. It is essential to recognize signs of discomfort and know how to intervene appropriately to ensure patient safety and comfort. Lowering the enema container height is a simple yet effective intervention that can make a significant difference in the patient's experience.