A nurse notes that her client's dressing has a scant amount of pale drainage and marks the area. The nurse knows this drainage is:

Sanguineous drainage.

Serous drainage.

Serosanguineous drainage.

Purulent drainage.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Sanguineous drainage consists primarily of fresh red blood and is common in the immediate postoperative period or when a wound is actively bleeding. It has a thick, bright red appearance because it contains a high concentration of red blood cells. The presence of sanguineous fluid indicates that capillaries have been damaged or that a vessel is leaking. In this scenario, the drainage is described as pale, which contradicts the deep red profile of pure sanguineous fluid.

Choice B rationale

Serous drainage is composed of the clear, watery portion of the blood known as serum. It is typically transparent or slightly yellow and lacks red blood cells or significant cellular debris. Serous fluid is a normal part of the inflammatory stage of wound healing and is often seen in blisters or clean, healing incisions. Because the nurse noted a pale color rather than a clear or yellow fluid, serous drainage alone does not fully describe the observation.

Choice C rationale

Serosanguineous drainage is a mixture of clear serous fluid and red sanguineous fluid, resulting in a pale, pink, or watery-red appearance. This is a very common finding in healing surgical wounds as the initial bleeding tapers off and mixes with inflammatory exudate. The description of pale drainage fits this profile perfectly, indicating that while some red blood cells are present, they are heavily diluted by the serum component of the wound exudate during healing.

Choice D rationale

Purulent drainage is a thick, opaque fluid that can be yellow, green, tan, or brown, often associated with a foul odor. It contains white blood cells, dead bacteria, and cellular debris, serving as a primary clinical indicator of wound infection. The description of pale drainage does not match the characteristic thick and cloudy nature of pus. Assessing for purulent discharge is critical because it signals a need for culture, sensitivity testing, and possible antibiotic therapy.

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Correct Answer is C

Explanation

Choice A rationale

Consuming all required fiber during a single meal is not recommended because it can cause significant gastrointestinal distress, including bloating, gas, and abdominal cramping. Fiber intake should be distributed evenly throughout the day across multiple meals to promote consistent peristalsis and easier passage of stool. A sudden bolus of fiber in the morning can overwhelm the digestive system and may not effectively manage chronic constipation as well as a steady, balanced intake of fibrous foods.

Choice B rationale

Drinking only two to three 8 oz glasses of water per day is insufficient for a client with chronic constipation. Adequate hydration is necessary to soften stool and allow fiber to work effectively. Most adults require at least 1,500 mL to 2,000 mL of fluid daily, which equates to roughly eight 8 oz glasses. Insufficient water intake while increasing fiber can actually worsen constipation by creating hard, dry stools that are difficult for the colon to move.

Choice C rationale

A high fiber diet is the primary non pharmacological intervention for establishing bowel regularity. Dietary fiber increases the bulk of the stool and stimulates the lining of the colon, which triggers the muscles to contract and move contents along. For clients with irregular bowel habits, consistent fiber intake helps regulate the timing and consistency of movements. Foods such as whole grains, fruits, and vegetables should be increased gradually to prevent discomfort and ensure long term adherence.

Choice D rationale

While many people believe that a daily bowel movement is necessary, the goal of therapy should be a frequency that is normal for the individual, which can range from three times per day to three times per week. Focusing on a daily movement can lead to the overuse of laxatives or unnecessary anxiety. The clinical goal is to ensure that stools are soft, easy to pass, and occur at a regular frequency without the need for straining or chemical stimulants.

A. "The client has a respiratory rate of 38/min.”. B. "The client has a history of COPD.”. C. "Should I increase the client's supplemental oxygen?" D. "I will obtain a sputum culture.”.

Correct Answer is A

Explanation

Choice A rationale

In the I-SBAR-R communication tool, the assessment component focuses on the nurse's current clinical findings and observations regarding the patient's status. Stating that the respiratory rate is 38 per minute provides a specific, objective clinical measurement that indicates the patient is in acute respiratory distress. The normal adult respiratory rate is 12 to 20 breaths per minute. Reporting this data allows the provider to understand the severity of the situation based on the nurse's immediate physical assessment.

Choice B rationale

Mentioning the history of COPD belongs in the background section of the I-SBAR-R tool. The background component provides context for the current situation by detailing the patient's medical history, previous treatments, or allergies. While this information is vital for the provider to understand the patient's baseline and underlying pathology, it is not part of the active assessment of the current acute problem. The assessment section should instead prioritize the current vital signs and physical manifestations.

Choice C rationale

Asking if the supplemental oxygen should be increased is part of the recommendation component of the I-SBAR-R tool. In the recommendation phase, the nurse suggests a specific intervention or asks for a particular order to address the problem identified in the assessment. While this is a critical part of the communication process, it occurs after the nurse has presented the assessment data. The recommendation is the final step where the nurse advocates for the patient's needs.

Choice D rationale

Stating the intention to obtain a sputum culture is also part of the recommendation or plan of action. It reflects a diagnostic step that the nurse proposes or anticipates based on the assessment findings. The assessment component itself is strictly for reporting what the nurse has observed or measured, such as breath sounds, oxygen saturation, or respiratory effort. Proposing future actions belongs at the end of the report to facilitate clear orders from the healthcare provider.

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A nurse notes that her client's dressing has a scant amount of pale drainage and marks the area. The nurse knows this drainage is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

Correct Answer is C

Explanation

A nurse is using the introduction, situation, background, assessment, recommendation, and readback (I-SBAR-R) communication tool when contacting a provider about a client who has COPD. Which of the following statements by the nurse should be included in the assessment component?

Correct Answer is A

Explanation

Some antibodies against foreign antigens can react to similar self-antigens, causing an autoimmune disease.

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