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

Answer and Explanation

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.

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Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

A. “I’m sorry, but you do not have the right to read your chart.” B. “You will have to sign a written request for access to your record.” C. “We’ll give you a copy of your records when we are preparing you for discharge.” D. “You will have to explain why you want to review your medical record.”

Correct Answer is B

Explanation

Choice A rationale:

Incorrect. Patients have a legal right to access their medical records under the Health Information Portability and Accountability Act (HIPAA). Denying access is a violation of patient rights and could lead to legal consequences.

Undermines patient autonomy and trust. Patients have a right to know what information is in their medical records and to participate in their own healthcare decisions. Denying access can erode trust in the healthcare system.

Potential for errors and misunderstandings. If patients cannot review their records, they may not be able to identify errors or misunderstandings that could impact their care.

Choice B rationale:

Correct. This response upholds patient rights while ensuring that the request for access is documented and handled appropriately.

Protects patient privacy and confidentiality. The written request process helps to ensure that only the patient or their authorized representative has access to the records.

Provides a mechanism for tracking and auditing access requests. This can help to prevent unauthorized access and ensure compliance with HIPAA regulations.

Choice C rationale:

Incorrect. Patients have a right to access their records at any time, not just when they are being discharged.

Delays access to information. Patients may need to review their records to make informed decisions about their care, even if they are not being discharged.

Potential for records to be lost or misplaced. There is a risk that records could be lost or misplaced if they are not provided to the patient until discharge.

Choice D rationale:

Incorrect. Patients do not need to provide a reason for wanting to access their medical records.

Intrusive and unnecessary. Patients may feel uncomfortable or embarrassed about having to explain their reasons for wanting to access their records.

Potential for discrimination. Patients may be less likely to request access to their records if they feel that they will be judged or questioned about their reasons for doing so.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a patient who requests to review his medical record. How should the nurse respond?

Correct Answer is B

Explanation

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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?