A nurse is caring for a patient who is 1 day postoperative following a cholecystectomy. The nurse suspects the patient's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Serosanguineous

Serous

Purulent

Sanguineous

Answer and Explanation

The Correct Answer is C

Choice A reason: Serosanguineous drainage is a mixture of blood and clear ﬂuid, not typically yellow and thick.

Choice B reason: Serous drainage is clear and watery, not yellow and thick.

Choice C reason: Purulent drainage is typically yellow and thick, indicating the presence of pus, which can be a sign of infection.

Choice D reason: Sanguineous drainage is fresh bleeding, bright red in color, not yellow and thick.

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Correct Answer is A

Explanation

Choice A reason: Respiratory acidosis is indicated by a pH lower than the normal range (7.35-7.45), combined with a CO2 level higher than the normal range (35-45 mmHg). In this scenario, the pH is 7.33, which is slightly acidic, and the CO2 is 50, which is elevated, suggesting that the lungs are not adequately removing CO2.

Choice B reason: Metabolic acidosis is characterized by a low pH and a low HCO3 level. However, in this case, the HCO3 is normal (22-26 mEq/L), ruling out metabolic acidosis.

Choice C reason: Metabolic alkalosis would present with a high pH and a high HCO3 level. Since the pH is low, metabolic alkalosis is not the correct answer.

Choice D reason: Respiratory alkalosis is characterized by a high pH and a low CO2 level. Given that the pH is low and the CO2 is high, respiratory alkalosis is not the condition indicated by these ABG results.

A. Administer sodium bicarbonate to the patient. B. Provide a paper bag for the patient to breathe into. C. Monitor the patient's head being between their knees. D. Administer acetazolamide to the patient.

Correct Answer is B

Explanation

Choice A reason: Administering sodium bicarbonate is not indicated for respiratory alkalosis as it is an alkalinizing agent and could worsen the condition.

Choice B reason: Breathing into a paper bag can help to rebreathe CO2, which can help correct the pH in cases of hyperventilation-induced respiratory alkalosis.

Choice C reason: Having the patient's head between their knees is not a standard intervention for respiratory alkalosis and could be uncomfortable or unsafe for the patient.

Choice D reason: Acetazolamide is a diuretic that can cause metabolic acidosis to compensate for respiratory alkalosis, but it is not typically used for acute management of hyperventilation.

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A nurse is caring for a patient who is 1 day postoperative following a cholecystectomy. The nurse suspects the patient's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Based on the ABG results: pH 7.33, CO2: 50, HCO3: 22, what acid-base imbalance is present?

Correct Answer is A

Explanation

A nurse is caring for a patient who has respiratory alkalosis and hyperventilating. Which of the following interventions should the nurse implement?

Correct Answer is B

Explanation

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