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?
Serosanguineous
Serous
Sanguineous
Purulent
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Encouraging increased fluid intake helps maintain blood volume and reduces viscosity, promoting circulation and lowering the risk of venous stasis and clot formation postoperatively.
Choice B rationale: Keeping the affected knee flexed impairs venous return and increases stasis, elevating the risk of thrombosis. Proper positioning with extension promotes circulation and reduces clot risk.
Choice C rationale: Prolonged bed rest contributes to immobility-induced venous stasis, a major risk factor for DVT. Early ambulation and leg exercises are essential to prevent thromboembolic events.
Choice D rationale: Massaging the calf of a postoperative patient is contraindicated due to the risk of dislodging a thrombus, potentially leading to a life-threatening pulmonary embolism.
Correct Answer is D
Explanation
Choice A rationale:
Hypovolemic shock is a type of shock that occurs when there is a significant loss of blood or fluid volume, leading to decreased cardiac output and tissue perfusion. This can be caused by severe bleeding, dehydration, burns, or other conditions that result in fluid loss. While anaphylaxis can involve some fluid shifts, it is not primarily characterized by a loss of blood or fluid volume.
Key features of hypovolemic shock that distinguish it from anaphylactic shock include:
Prominent signs of dehydration: Dry skin and mucous membranes, decreased urine output, sunken eyes, and poor skin turgor.
Hemodynamic changes: Tachycardia, narrow pulse pressure, and cold extremities due to vasoconstriction to maintain blood pressure.
Laboratory findings: Elevated hematocrit and blood urea nitrogen (BUN) levels, indicating hemoconcentration and decreased kidney perfusion.
Choice B rationale:
Obstructive shock is a type of shock that occurs when there is an obstruction to blood flow, preventing adequate circulation to the body's tissues. This can be caused by conditions such as pulmonary embolism, cardiac tamponade, or tension pneumothorax. Anaphylaxis does not involve a physical obstruction to blood flow.
Key features of obstructive shock that distinguish it from anaphylactic shock include:
Evidence of the underlying obstruction: Jugular venous distension (cardiac tamponade), muffled heart sounds (cardiac tamponade), or respiratory distress (pulmonary embolism or tension pneumothorax).
Distinctive hemodynamic changes: Equalization of diastolic pressures between the right and left ventricles (cardiac tamponade).
Specific imaging findings: Enlarged cardiac silhouette on chest X-ray (pericardial effusion), filling defects in the pulmonary arteries on CT angiography (pulmonary embolism), or hyperexpanded lung fields with a deviated trachea on chest X-ray (tension pneumothorax).
Choice C rationale:
Cardiogenic shock is a type of shock that occurs when the heart is unable to pump enough blood to meet the body's needs. This can be caused by conditions such as heart attack, heart failure, or cardiomyopathy. Anaphylaxis does not primarily involve a failure of the heart's pumping function.
Key features of cardiogenic shock that distinguish it from anaphylactic shock include:
Evidence of heart failure: Pulmonary edema, elevated jugular venous pressure, and a third heart sound (S3 gallop).
Electrocardiogram (ECG) changes: ST-segment elevation or depression, Q waves, or other signs of myocardial ischemia or infarction.
Elevated cardiac enzymes: Troponin and creatine kinase-MB (CK-MB) levels, indicating heart muscle damage.
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