A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.
The nurse should identify which of the following findings as indicative of an infection?
Milky fluid.
Bloody fluid.
Viscous fluid.
Purulent fluid.
The Correct Answer is D
Choice A rationale
Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.
Choice B rationale
Bloody fluid may indicate trauma or malignancy but not necessarily infection.
Choice C rationale
Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.
Choice D rationale
Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cyanosis is a late sign of hypoxemia and not the most common initial manifestation of ARDS. It indicates severe oxygen deprivation but doesn’t typically appear first.
Choice B rationale
Diaphoresis, or excessive sweating, can occur with many conditions causing distress, but it’s not specifically the most common presenting symptom of ARDS. It's more of a nonspecific symptom of stress.
Choice C rationale
Somnolence, or drowsiness, might occur in severe respiratory distress when oxygen levels drop significantly, but it’s not the primary or most common presenting manifestation of ARDS.
Choice D rationale
Dyspnea, or difficulty breathing, is the hallmark of ARDS and the most common presenting symptom. It occurs due to the acute onset of severe hypoxemia caused by the underlying pathophysiology of ARDS.
Correct Answer is A
Explanation
Choice A rationale
Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.
Choice B rationale
Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.
Choice C rationale
Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.
Choice D rationale
Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.
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