Physiological Integrity 2 — Questions and Answers

Question 1: A nurse is caring for a client who returns from surgery with a Jackson-Pratt (JP) drain in place. Which action should the nurse take to maintain proper function of the drain?

Keep the bulb inflated to prevent excessive suction
Empty and re-compress the bulb every 8 hours or when half full (Correct answer)
Irrigate the drain with normal saline every 4 hours
Secure the drain tubing to the wound dressing to prevent movement

Correct answer: Empty and re-compress the bulb every 8 hours or when half full

Jackson-Pratt drains work on gentle suction created by compressing the bulb. The nurse empties and re-compresses (re-establishes suction) the bulb when it is half full or per facility policy, typically every 8 hours, to maintain effective drainage.

The Jackson-Pratt (JP) drain is a closed, low-pressure suction device used after surgery to remove blood, serum, and lymph from the surgical site, preventing hematoma or seroma formation. It consists of a perforated drain tube attached to a small collapsible bulb reservoir. Mechanism: The bulb is compressed (flattened) before inserting the stopper, creating negative pressure (suction). As the bulb slowly expands, it draws fluid from the wound through the perforated tubing into the bulb. Nursing care of a JP drain: Empty the drain when half full or at least every 8 hours (per facility policy). To empty: open the stopper port, pour contents into a graduated container, measure and record the output (noting color and consistency), wipe the port with alcohol, then re-compress the bulb firmly and reinsert the stopper before releasing — this re-establishes the suction. The nurse should document output characteristics: sanguineous (bright red blood, first 24 hours), serosanguineous (pink, thin), or serous (clear/pale yellow) drainage. Sudden increase in drainage, foul odor, purulent drainage, or bright red blood after the first 24 hours should be reported. JP drains are not irrigated routinely. The bulb should not be inflated (filled) — it creates suction by being deflated/compressed. The tubing must remain free of kinks but should not be anchored to the wound dressing.

Question 2: A nurse is caring for a client 12 hours post-operative following a right colostomy. The nurse assesses the stoma and notes it is dark purple-black in color. Which action is most appropriate?

Document the finding as an expected post-operative change
Apply a warm compress to the stoma to improve circulation
Notify the surgeon immediately, as this finding indicates stoma ischemia (Correct answer)
Increase the client's oral fluid intake to improve blood flow

Correct answer: Notify the surgeon immediately, as this finding indicates stoma ischemia

A stoma that is dark purple or black indicates ischemia or necrosis — a surgical emergency. A healthy stoma should be pink or red and moist. The surgeon must be notified immediately as this finding may require emergent surgical intervention.

Stoma assessment is a critical nursing skill following ostomy surgery. Normal stoma characteristics: the stoma should be pink to red (similar to the buccal mucosa/inside of the mouth), moist, and slightly raised above skin level. It will bleed slightly when touched, which is normal due to its rich blood supply. Abnormal findings and their significance: - Dark purple or black stoma: indicates vascular compromise (ischemia or necrosis) — surgical emergency. Caused by tension on the mesentery, arterial occlusion, or venous congestion. Requires immediate surgical notification and likely return to the operating room. - Pale or white stoma: possible anemia or reduced blood flow. - Excessive swelling (edema): more common in the first 24-72 hours, can compress blood supply if severe. - Stoma retraction (receding below skin level): can cause leakage and skin problems. - Stomal prolapse (extending far out): requires evaluation. No warm compress, increased fluids, or documentation would be appropriate when the stoma is ischemic — these delay critical intervention. The immediate life-threatening risk is bowel necrosis and perforation, which can lead to peritonitis and sepsis. Early recognition and prompt surgical consultation are lifesaving.

Question 3: A nurse is performing a neurological assessment on a client with a suspected stroke. Which finding requires the most urgent intervention?

Facial drooping on the left side
Slurred speech
Glasgow Coma Scale score of 8 (Correct answer)
Blood pressure of 162/90 mmHg

Correct answer: Glasgow Coma Scale score of 8

A Glasgow Coma Scale (GCS) score of 8 indicates severe neurological impairment with significant risk of loss of protective airway reflexes. This is the most urgent finding, as airway protection is the priority (GCS ≤8 typically necessitates intubation consideration).

The Glasgow Coma Scale (GCS) assesses level of consciousness by evaluating three responses: Eye opening (1-4), Verbal response (1-5), and Motor response (1-6). The maximum score is 15 (fully conscious). A GCS of 8 or below indicates severe brain injury or impairment and is the clinical threshold at which loss of protective airway reflexes (gag reflex, cough) becomes a significant risk. The clinical guideline 'GCS ≤8, intubate' reflects the urgency of airway management in severely obtunded patients. Without a protected airway, the client is at risk for aspiration, hypoxia, hypercapnia, and respiratory arrest. The immediate nursing priority is airway assessment, positioning (HOB 30 degrees if tolerated, unless contraindicated), suction availability, oxygen delivery, and emergency notification for potential intubation. Facial drooping and slurred speech are classic stroke symptoms (FAST: Face, Arms, Speech, Time) that require urgent stroke protocol activation — but they do not indicate immediate airway compromise in the absence of other concerning findings. Hypertension (162/90 mmHg) in acute stroke is often permissive — acute blood pressure reduction can worsen cerebral ischemia if aggressive. Blood pressure management in acute stroke is controlled per protocol, typically not lowering unless specific thresholds are met (e.g., >220/120 mmHg for ischemic stroke).

Question 4: A nurse is caring for a client who is 2 days post-operative after abdominal surgery. The client's wound is closed with staples. The nurse notes the wound edges are approximated, with minimal serous drainage on the dressing. Which term best describes this type of wound healing?

Secondary intention
Tertiary intention (delayed primary closure)
Primary intention (Correct answer)
Granulation healing

Correct answer: Primary intention

Primary intention healing occurs when wound edges are surgically approximated (closed with sutures, staples, or surgical tape), resulting in minimal tissue loss and a clean, healing wound with little scarring.

Wound healing classification describes how a wound is closed and how it heals. Understanding these categories helps nurses accurately assess wounds and implement appropriate interventions. Primary intention: Wound edges are surgically approximated (brought together) with sutures, staples, skin closure strips, or tissue glue. This results in minimal tissue loss, rapid healing, and minimal scarring. Examples: surgical incisions, sutured lacerations. The healing process: within 24-48 hours, epithelial cells migrate across the incision; by day 3, collagen forms; tensile strength increases over weeks to months. Secondary intention: Wound is left open and heals from the inside out through granulation tissue formation, contraction, and epithelialization. Used for infected wounds, heavily contaminated wounds, or wounds with significant tissue loss. Results in more scarring and takes longer. Example: pressure injuries, infected surgical wounds left open. Tertiary intention (delayed primary closure): Wound is left open initially (usually due to infection or contamination), cleaned, and then surgically closed after 4-5 days once infection is controlled. This combines elements of both primary and secondary intention. In this clinical scenario, the wound has staples (surgically approximated edges), is well-approximated, and has minimal serous drainage — all consistent with normal primary intention healing on post-operative day 2.

Question 5: A nurse is assessing an adult client's blood pressure in the right arm and obtains a reading of 148/92 mmHg. Before documenting hypertension, which action is most appropriate?

Document hypertension and notify the provider immediately
Administer the prescribed antihypertensive medication
Obtain the blood pressure in both arms and compare, and repeat in the same arm after 5 minutes (Correct answer)
Ask the client if they have recently exercised or consumed caffeine

Correct answer: Obtain the blood pressure in both arms and compare, and repeat in the same arm after 5 minutes

A single elevated blood pressure reading is not sufficient to diagnose or document hypertension. The nurse should confirm the reading by measuring in both arms (to detect coarctation or peripheral vascular disease) and repeating after 5 minutes to eliminate transient elevation.

Accurate blood pressure assessment requires proper technique and interpretation. A single elevated reading may be caused by white coat hypertension, pain, anxiety, recent activity, caffeine, a full bladder, improper cuff size, or positional artifact — not necessarily true hypertension. Accurate blood pressure assessment technique includes: client rested in a seated position for at least 5 minutes, feet flat on floor, arm at heart level, appropriate cuff size (cuff bladder encircles 80% of arm), no talking during measurement. Multiple readings should be obtained. Measuring in both arms is recommended for the initial assessment to detect a significant inter-arm difference (>10-15 mmHg), which may indicate subclavian artery stenosis or aortic coarctation. Blood pressure should be taken in the arm with the higher reading for subsequent measurements. The AHA/ACC guidelines define hypertension as persistent blood pressure ≥130/80 mmHg across multiple readings on multiple occasions. Documenting hypertension based on a single reading can lead to unnecessary medication changes or diagnostic workup. Repeating the measurement after 5 minutes and comparing both arms provides a more accurate baseline before clinical decisions are made.

Question 6: A nurse is caring for a client with chronic kidney disease (CKD) who has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement first?

Administer sodium polystyrene sulfonate (Kayexalate) as ordered
Obtain an ECG to assess for cardiac effects of hyperkalemia (Correct answer)
Restrict dietary potassium intake
Administer IV calcium gluconate as ordered

Correct answer: Obtain an ECG to assess for cardiac effects of hyperkalemia

The most immediate risk from hyperkalemia (K+ 6.2 mEq/L) is life-threatening cardiac dysrhythmia. Obtaining an ECG is the priority assessment to determine the cardiac effects and guide urgency of treatment.

Hyperkalemia (serum potassium >5.0 mEq/L) is a potentially life-threatening electrolyte imbalance most commonly seen in clients with renal failure, metabolic acidosis, crush injuries, or use of ACE inhibitors/potassium-sparing diuretics. A potassium of 6.2 mEq/L is significantly elevated and requires urgent assessment and intervention. Cardiac effects of hyperkalemia progress with severity: first, peaked T waves; then widened QRS complex; then flat or absent P waves; then a sine wave pattern; finally ventricular fibrillation or asystole. Without cardiac monitoring/ECG, the nurse cannot determine where on this progression the client sits — which directly affects treatment urgency. ECG assessment is the priority because: if severe cardiac changes are present (widened QRS, dysrhythmia), IV calcium gluconate must be given immediately (it stabilizes the cardiac membrane and buys time, though it does not lower potassium level); if cardiac changes are less severe, other interventions (sodium bicarbonate, insulin/dextrose, Kayexalate, dialysis) can be implemented over a longer timeframe. The treatment hierarchy for hyperkalemia: (1) Cardiac membrane stabilization: IV calcium gluconate (when ECG changes present). (2) Potassium redistribution: IV insulin + dextrose, sodium bicarbonate (shift K+ into cells). (3) Potassium removal: Kayexalate (GI elimination), loop diuretics, dialysis (definitive in CKD). ECG assessment guides which interventions are most urgent.

Physiological Integrity 2

A nurse is caring for a client who returns from surgery with a Jackson-Pratt (JP) drain in place.
Which action should the nurse take to maintain proper function of the drain?