A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.
What type of drainage should the nurse report?

Serosanguineous

Serous

Sanguineous

Purulent

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is A

Explanation

Choice A rationale:

Painful urination (dysuria) can be a sign of several conditions that could potentially affect the client's IVP or indicate a need for further assessment. These conditions include:

Urinary tract infection (UTI): UTIs are common in clients with recurrent kidney stones, and they can cause inflammation and pain in the urinary tract. If a client has a UTI, it's important to treat it before the IVP to reduce the risk of spreading the infection to the kidneys.

Kidney stone passage: The client's history of kidney stones makes it possible that the pain could be due to the passage of a stone. This would be important information for the healthcare team to know, as it could affect the interpretation of the IVP results.

Other urological conditions: There are other urological conditions, such as bladder or urethral strictures, that can also cause painful urination. These conditions might also need to be considered and assessed for.

It's important for the nurse to collect more data about the client's painful urination to determine the underlying cause and whether it could impact the IVP. This might include asking questions about:

The severity and duration of the pain

Any other associated symptoms, such as fever, urgency, or frequency The client's history of UTIs or kidney stones

Any recent changes in urinary habits

Based on this additional information, the nurse can then collaborate with the healthcare team to determine the best course of action, which might include:

Further assessment, such as a urinalysis or urine culture Treatment for a UTI, if present

Pain management

Rescheduling the IVP, if necessary

A. Chronic pain could cause restlessness, pacing, grimacing, and other facial expressions of pain. B. Chronic pain is limited and short in duration. C. A patient with chronic pain may have physical signs of tissue injury. D. Chronic pain may not manifest in a change of vital signs.

Correct Answer is A

Explanation

Choice A rationale:

Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.

They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.

It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.

Choice B rationale:

Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.

This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.

Choice C rationale:

While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.

In some cases, the underlying cause of chronic pain may be unknown.

Choice D rationale:

Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.

Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.

Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.

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A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.What type of drainage should the nurse report?

Nursing Test Bank

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A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.
What type of drainage should the nurse report?