A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?

Purulent

Serous

Sanguineous

Hyperemia

Answer and Explanation

The Correct Answer is C

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

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Correct Answer is C

Explanation

A. Telling the child that it will not hurt may not be effective, as children may still have anxiety or fear related to the unknown.

B. Forcing a child or having the parent hold tightly may increase anxiety and make the child more resistant to the procedure.
C. Allowing the child to operate the equipment can give the child a sense of control and involvement, increasing cooperation.
D. Deferring the procedure until the next visit may not be practical or necessary if alternative strategies can be employed to promote cooperation.

A. Hold the dropper 1/2 inch (1 cm) above the ear canal during administration. B. Place a cotton ball into the inner ear canal for 30 min following administration. C. Straighten the ear canal by pulling the auricle down and back prior to administration. D. Apply pressure to the nasolacrimal duct following administration.

Correct Answer is A

Explanation

A. Holding the dropper 1/2 inch (1 cm) above the ear canal during administration (option A) is indeed the correct action when administering otic medications. This distance helps to ensure that the medication is properly instilled into the ear canal without touching the dropper tip to the skin or ear canal, reducing the risk of contamination.
B. Placing a cotton ball into the inner ear canal is not necessary following otic administration. It may cause unnecessary discomfort to the client.

C. Straightening the ear canal by pulling the auricle down and back can make the medication trickle out of the ear. It should be held outward and upward.
D. Applying pressure to the nasolacrimal duct is a technique used for ophthalmic medications, not otic medications.

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A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?

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