A 60-year-old client with a surgical wound is showing signs of serous drainage. Which of the following should the nurse document about the drainage?
Watery and clear or slightly yellow
Pale and pink
Reddish and thick
Thick, yellow, and foul-smelling
The Correct Answer is A
A. Watery and clear or slightly yellow: Serous drainage is typically thin, watery, and clear or slightly yellow in color. It is composed primarily of serum and is a normal finding in the early stages of wound healing, indicating that the inflammatory phase is progressing appropriately.
B. Pale and pink: Pale pink drainage is usually described as serosanguineous, which contains both serum and small amounts of blood. It is not the same as purely serous drainage.
C. Reddish and thick: Thick, red drainage is indicative of sanguineous or hemorrhagic drainage, suggesting active bleeding or trauma to the wound. This differs from serous drainage and may require closer assessment.
D. Thick, yellow, and foul-smelling: This description corresponds to purulent drainage, which indicates infection. Serous drainage is clear and non-purulent, making this inconsistent with the client’s presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Set a goal to maintain blood glucose levels within normal range: In the planning phase, establishing measurable and achievable goals is the priority. Setting a target for blood glucose guides the development of interventions and provides a benchmark for evaluating the effectiveness of care.
B. Document the patient's blood glucose readings: Documentation is part of the implementation and evaluation phases. While important for tracking trends, it does not establish the direction of care or plan interventions.
C. Teach the patient about carbohydrate counting: Patient education is an intervention that supports achieving the goal, but it cannot be implemented effectively without first defining the desired outcome.
D. Administer insulin as prescribed: Administering insulin is an implementation action. While critical for management, it is guided by the plan and goals set during the planning phase, rather than being the initial planning step.
Correct Answer is A
Explanation
A. "It must be really difficult to face such uncertainty. How can I support you through this?": This response acknowledges the client’s emotions, validates their experience, and invites collaboration. Demonstrating empathy involves understanding feelings without judgment and offering support tailored to the client’s needs.
B. "Let's focus on your treatment plan for now": This response redirects attention away from the client’s emotional concerns. While planning care is important, it does not address the client’s fear or provide emotional support.
C. "I'm sure everything will be alright.": This statement minimizes the client’s feelings and may invalidate their concerns. Offering reassurance without understanding can reduce trust and impede open communication.
D. "You should talk to a counselor about these feelings.": Referral to counseling can be appropriate, but simply instructing the client to seek help does not acknowledge or validate their current emotions. It lacks empathetic engagement in the moment.
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