When changing the dressing on the patient’s right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?
Sanguineous
Serous
Serosanguineous
Purulent
The Correct Answer is C
Choice A rationale
Sanguineous drainage is indicative of active bleeding and is typically bright red due to the presence of red blood cells. This type of drainage is not yellow-red and is not consistent with the description provided.
Choice B rationale
Serous drainage is clear and watery, and it is the fluid that is seen in blisters. It does not have a yellow-red color, so it does not match the description of the drainage observed.
Choice C rationale
Serosanguineous drainage is a mixture of serous and sanguineous drainage. It is typically light red or pink in color, which corresponds with the moist yellow-red stain described, indicating the presence of both plasma and red blood cells.
Choice D rationale
Purulent drainage is thick and opaque, usually yellow, green, or brown, and is associated with infection. The description of a yellow-red stain does not suggest that the drainage is purulent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A:
This is the correct choice. The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half full, the suction pressure is diminished. Thus it is appropriate to empty it and record the amount of drainage you discard.
Choice B:
While it's important to keep the surgeon informed about the patient's condition, in this case, the purpose of the Jackson-Pratt drain is to aspirate drainage, such as excess blood, from the wound. Many factors are involved in determining what an acceptable amount of drainage is; however, excessive blood loss that must be reported is likely to affect the patient's vital signs.
Choice C:
The surgeon determines when to remove the drain, and in most cases, a patent and functioning drain remains in place for a few days.
Choice D:
Leaving the reservoir half full until the end of the shift is not recommended. The suction pressure is diminished when the reservoir is half full, which could affect the drain's effectiveness.
Correct Answer is C
Explanation
Choice A rationale
Excessive gas is not typically an indication of wound dehiscence. While it may cause discomfort, it does not suggest that the wound layers have separated.
Choice B rationale
A complaint of constipation is a common postoperative concern due to decreased mobility and use of narcotics but is not a sign of wound dehiscence.
Choice C rationale
Increased drainage from the wound, especially if the fluid is clear or serous, can be an early sign of dehiscence, indicating that the wound layers are separating and fluid is accumulating.
Choice D rationale
Increased pallor of the surgical site might indicate poor perfusion but is not a direct sign of dehiscence. Dehiscence would more likely show signs of inflammation or unusual discharge.
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