A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.
What type of drainage should the nurse report?

Choice A rationale:

Serosanguineous drainage is a mixture of blood serum and blood. It is typically thin and watery, with a pinkish or reddish hue.

It is common in the early stages of wound healing, as small blood vessels are injured and release their contents. However, it's not consistent with the yellow and thick drainage described in the question, making it an unlikely choice.

Choice B Rationale:

Serous drainage is clear and watery, composed primarily of blood plasma.

It's also common in the early stages of wound healing and is considered a normal part of the process. However, the clear and watery nature of serous drainage doesn't match the thick, yellow drainage described in the question, ruling out this option.

Choice C Rationale:

Sanguineous drainage is composed primarily of fresh blood.

It's often bright red and may be thick or thin, depending on the amount of bleeding. While sanguineous drainage can indicate a problem, it's typically associated with active bleeding or recent trauma. The yellow color of the drainage in the question makes this choice less likely.

Choice D Rationale:

Purulent drainage is a thick, yellow, green, or brown fluid that often has a foul odor.

It's a sign of infection, as it contains dead white blood cells, bacteria, and debris. The yellow and thick consistency of the drainage described in the question strongly suggests purulent drainage, making it the most likely answer.

Key Points:

The color, consistency, and odor of wound drainage can provide valuable clues about the healing process and potential complications.

Purulent drainage is a hallmark of infection and requires prompt attention.

Nurses play a crucial role in assessing wound drainage and reporting any concerns to the healthcare team.

Establishing an open airway is the most crucial and immediate action in any respiratory arrest situation, including when a client has heart failure. Here's a detailed explanation: 1. Airway patency is paramount for survival: Oxygen, the essential element for life, cannot reach the lungs and bloodstream without a clear and unobstructed airway. Brain cells are extremely sensitive to oxygen deprivation and start to die within minutes without it, leading to irreversible brain damage or death. 2. Respiratory arrest in heart failure: Heart failure often leads to fluid buildup in the lungs (pulmonary edema), which can significantly impair breathing. Respiratory arrest can occur due to: Excessive fluid accumulation in the lungs. Weakening of respiratory muscles due to fatigue or heart failure itself. Arrhythmias or heart blocks affecting heart's ability to pump effectively. 3. Steps to establish an open airway: Head tilt-chin lift maneuver: Gently tilt the head back and lift the chin to open the airway. Jaw thrust maneuver: If a neck injury is suspected, use the jaw thrust maneuver to avoid further injury. Removal of any visible obstructions: Clear any visible foreign objects or fluids from the mouth or throat. Use of airway adjuncts: Consider using oral or nasal airways to maintain airway patency, especially if the patient is unconscious.

4. Rationale for other choices:

A. Auscultating for breath sounds: While important for assessment, it does not address the immediate need to establish airflow.

C. Establishing IV access: IV access is necessary for medications and fluids, but airway takes priority in respiratory arrest.

D. Feeling for a carotid pulse: Checking for a pulse is essential, but only after ensuring an open airway and attempting to restore breathing.

5. Importance of prioritizing airway: Establishing an open airway allows for potential rescue breaths and ventilation, which can help restore oxygen levels and prevent further deterioration. Even if a pulse is present, without a clear airway, oxygen cannot reach the vital organs, leading to organ failure and death.