A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?

Purulent

Serous

Sanguineous

Hyperemia

Answer and Explanation

The Correct Answer is C

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

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Correct Answer is A

Explanation

A. Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions.
B. Postural drainage is typically done before meals to avoid potential nausea during the procedure.
C. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure.
D. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.

Correct Answer is ["150"]

Explanation

The question is about calculating the IV infusion rate for a given solution and volume.

The formula for the infusion rate is: (volume in mL / time in hours) x drop factor in gtts/mL = infusion rate in gtts/min

The drop factor is usually given on the IV tubing package and varies depending on the type of tubing used.

For this question, we can assume a drop factor of 15 gtts/mL, which is common for macrodrip tubing.

Plugging in the numbers, we get: (1200 mL / 8 hr) x 15 gtts/mL = 2250 gtts/hr

To convert from gtts/hr to mL/hr, we divide by the drop factor: 2250 gtts/hr / 15 gtts/mL = 150 mL/hr

Therefore, the nurse should set the IV pump to deliver 150 mL/hr.

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A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?

Correct Answer is A

Explanation

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1,200 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero is applicable. Do not use a trailing zero.)

Correct Answer is ["150"]

Explanation

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