How should a nurse document the presence of thick, creamy yellow discharge on a patient’s dressing?
Purulent drainage
Serosanguineous drainage
Serous drainage
Sanguineous drainage
The Correct Answer is A
Choice A rationale:
Thick, creamy yellow discharge is a hallmark characteristic of purulent drainage. This type of drainage is commonly referred to as pus and is indicative of an infection within the wound. It is composed of white blood cells, dead bacteria, cellular debris, and inflammatory cells, giving it its characteristic opaque, thick, and yellowish appearance.
Purulent drainage is a significant clinical finding that requires prompt attention and intervention. Early identification and management of wound infections can prevent complications such as abscess formation, cellulitis, sepsis, and delayed wound healing.
Accurate documentation of purulent drainage is essential for communication among healthcare providers, monitoring wound progress, and guiding treatment decisions.
Choice B rationale:
Serosanguineous drainage is a mixture of serous fluid (clear, thin, and watery) and blood. It often appears pink or slightly red and is commonly observed in the early stages of wound healing or after dressing changes. While it may contain a small amount of blood, it lacks the thick, creamy consistency and yellow color that are characteristic of purulent drainage.
Choice C rationale:
Serous drainage is clear, thin, and watery, resembling plasma. It is a normal part of the wound healing process and is often seen in the early inflammatory stage. It does not contain the thick consistency or yellow coloration that are indicative of purulent drainage.
Choice D rationale:
Sanguineous drainage is composed primarily of fresh blood. It is bright red in color and typically indicates active bleeding within the wound. It does not exhibit the thick, creamy consistency or yellow hue that are characteristic of purulent drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.
Correct Answer is C
Explanation
Rationale for Choice A:
Mixing insulin detemir and insulin aspart in the same syringe is not recommended due to their differing physicochemical properties and potential for altered absorption and action profiles.
It's crucial to follow manufacturer guidelines, as mixing may lead to suboptimal glycemic control or unpredictable insulin activity.
Rationale for Choice B:
The order of mixing insulin detemir and insulin aspart, even if done incorrectly in the same syringe, would not significantly impact the overall contraindication of mixing them.
The primary concern remains the potential for altered pharmacodynamics and pharmacokinetics when these insulins are combined.
Rationale for Choice C:
Drawing up insulin aspart and insulin detemir in separate syringes is the correct procedure.
This approach ensures that each insulin maintains its intended action profile and absorption characteristics, leading to more predictable glycemic control.
It also aligns with best practices and guidelines for insulin administration.
Rationale for Choice D:
While drawing up insulin detemir first in a separate syringe is technically correct, it offers no specific advantage over drawing up insulin aspart first in a separate syringe.
The key principle is to avoid mixing the two insulins in the same syringe.
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