A nurse is assessing a patient with a Jackson-Pratt drain. The drainage has changed from red to pink over the past 24 hours. Which type of drainage is the patient exhibiting?
Serous
Sanguineous
Purulent
Serosanguineous
The Correct Answer is D
A. Serous: Serous drainage consists primarily of plasma and is characterized by a clear, pale yellow, or straw-colored fluid. It contains minimal cellular components and emerges from superficial wounds or during the initial inflammatory phase of healing. The presence of pink coloration indicates erythrocytes are present, which differentiates it from purely serous fluid.
B. Sanguineous: Sanguineous drainage is rich in red blood cells, resulting in a bright red, often thick fluid that reflects active hemorrhage. It is commonly observed immediately postoperatively or in wounds with significant vascular disruption. A shift from red to pink in the patient’s drainage suggests dilution with serous fluid and a decrease in active bleeding.
C. Purulent: Purulent drainage is composed of leukocytes, necrotic tissue, and bacteria, giving it a thick, opaque appearance that can range from yellow to green or brown. It is indicative of an ongoing infectious process or significant inflammatory response. The patient’s pink drainage lacks the turbidity, color, and odor characteristic of purulent material.
D. Serosanguineous: Serosanguineous drainage is a mixture of serum and red blood cells, producing a light pink to pale red fluid. It commonly appears in surgical or traumatic wounds as bleeding decreases and serous exudate mixes with residual blood. This type of drainage reflects the ongoing vascular healing process, where capillary leakage continues alongside plasma exudation, consistent with the observed transition from red to pink over 24 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sensory overload: Sensory overload occurs when a client is exposed to excessive stimuli, such as noise, light, or activity, which can lead to agitation, anxiety, or confusion. The client’s symptoms of boredom and depression do not reflect an overwhelming sensory environment.
B. Sensory deprivation: Sensory deprivation results from insufficient or monotonous stimuli, leading to psychological and behavioral symptoms such as boredom, restlessness, and depression. In a nursing home setting, limited interaction, lack of environmental stimulation, or isolation can precipitate this condition, matching the client’s observed behaviors.
C. Impaired communication: While impaired communication may contribute to frustration or social withdrawal, it primarily affects the client’s ability to convey or understand information. The behavioral symptoms described are more directly linked to inadequate sensory input rather than the inability to communicate.
D. Sensory perception deficits: Sensory perception deficits involve the loss or alteration of a specific sense (vision, hearing, touch). While this can influence interaction with the environment, the client’s symptoms suggest a broader lack of stimulation rather than a deficit in sensory processing itself.
Correct Answer is C
Explanation
A. Notify the physician immediately of this unexpected finding: While loss of suction should be reported if it cannot be corrected, immediate notification is not the first action. The nurse should first attempt standard troubleshooting to re-establish suction, as this is often a correctable issue without needing urgent physician intervention.
B. Allow gravity to assist with draining by repositioning the drain to a position lower than the client: Positioning the drain lower may facilitate passive drainage, but it does not restore the negative pressure needed for the Jackson-Pratt drain to function effectively. Relying solely on gravity can lead to fluid accumulation and increase the risk of infection.
C. Re-establish the negative pressure by opening the valve and decompressing the bulb: The Jackson-Pratt drain relies on negative suction to remove fluid from the wound site. If suction is lost, the nurse should compress the bulb after emptying it and closing the valve to restore negative pressure, ensuring continued drainage and reducing the risk of hematoma, or infection.
D. Switch the client's drain to a Hemovac drain to improve suction: Replacing the drain is not the first-line action. Hemovac drains are a different device, and switching requires a physician’s order. The priority is to troubleshoot and restore the function of the existing Jackson-Pratt drain before considering device replacement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.