A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse’s first response?

Choice A rationale:

Serosanguineous drainage is a mixture of blood serum and blood. It is typically thin and watery, with a pinkish or reddish hue.

It is common in the early stages of wound healing, as small blood vessels are injured and release their contents. However, it's not consistent with the yellow and thick drainage described in the question, making it an unlikely choice.

Choice B Rationale:

Serous drainage is clear and watery, composed primarily of blood plasma.

It's also common in the early stages of wound healing and is considered a normal part of the process. However, the clear and watery nature of serous drainage doesn't match the thick, yellow drainage described in the question, ruling out this option.

Choice C Rationale:

Sanguineous drainage is composed primarily of fresh blood.

It's often bright red and may be thick or thin, depending on the amount of bleeding. While sanguineous drainage can indicate a problem, it's typically associated with active bleeding or recent trauma. The yellow color of the drainage in the question makes this choice less likely.

Choice D Rationale:

Purulent drainage is a thick, yellow, green, or brown fluid that often has a foul odor.

It's a sign of infection, as it contains dead white blood cells, bacteria, and debris. The yellow and thick consistency of the drainage described in the question strongly suggests purulent drainage, making it the most likely answer.

Key Points:

The color, consistency, and odor of wound drainage can provide valuable clues about the healing process and potential complications.

Purulent drainage is a hallmark of infection and requires prompt attention.

Nurses play a crucial role in assessing wound drainage and reporting any concerns to the healthcare team.

The correct answer is Choice A.

Choice A rationale: Encouraging increased fluid intake helps maintain blood volume and reduces viscosity, promoting circulation and lowering the risk of venous stasis and clot formation postoperatively.

Choice B rationale: Keeping the affected knee flexed impairs venous return and increases stasis, elevating the risk of thrombosis. Proper positioning with extension promotes circulation and reduces clot risk.

Choice C rationale: Prolonged bed rest contributes to immobility-induced venous stasis, a major risk factor for DVT. Early ambulation and leg exercises are essential to prevent thromboembolic events.

Choice D rationale: Massaging the calf of a postoperative patient is contraindicated due to the risk of dislodging a thrombus, potentially leading to a life-threatening pulmonary embolism.