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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Respiratory acidosis is characterized by a low pH (less than 7.35), a high PaCO2 (greater than 45 mm Hg), and a normal or high HCO3 (22-26 mEq/L). It occurs when there is a buildup of carbon dioxide in the blood due to impaired ventilation.
The patient's ABGs do not align with respiratory acidosis because the pH is elevated (7.6), and the PaCO2 is within the normal range (40 mm Hg).
Choice B rationale:
Respiratory alkalosis is characterized by a high pH (greater than 7.45), a low PaCO2 (less than 35 mm Hg), and a normal or low HCO3 (22-26 mEq/L). It occurs when there is excessive loss of carbon dioxide through hyperventilation.
The patient's ABGs do not align with respiratory alkalosis because the HCO3 is elevated (32 mEq/L), which is not typical for this condition.
Choice C rationale:
Metabolic acidosis is characterized by a low pH (less than 7.35), a normal or low PaCO2 (less than 40 mm Hg), and a low HCO3 (less than 22 mEq/L). It occurs when there is an excess of acid in the body or a loss of bicarbonate.
The patient's ABGs do not align with metabolic acidosis because the pH is elevated (7.6), and the HCO3 is elevated (32 mEq/L).
Choice D rationale:
Metabolic alkalosis is characterized by a high pH (greater than 7.45), a normal or high PaCO2 (40-45 mm Hg), and an elevated HCO3 (greater than 26 mEq/L). It occurs when there is an excess of bicarbonate in the body or a loss of acid.
The patient's ABGs align with metabolic alkalosis because of the high pH (7.6), normal PaCO2 (40 mm Hg), and elevated HCO3 (32 mEq/L).
Correct Answer is B
Explanation
Choice A rationale:
Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.
While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.
It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice B rationale:
Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).
It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.
This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.
Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.
Choice C rationale:
Naloxone is not effective in treating nausea.
In fact, it can actually worsen nausea in some patients.
This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.
Choice D rationale:
Naloxone is not effective in treating urinary retention.
Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.
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.