How should a nurse document the presence of thick, creamy yellow discharge on a patient’s dressing?
Purulent drainage
Serosanguineous drainage
Serous drainage
Sanguineous drainage
The Correct Answer is A
Choice A rationale:
Thick, creamy yellow discharge is a hallmark characteristic of purulent drainage. This type of drainage is commonly referred to as pus and is indicative of an infection within the wound. It is composed of white blood cells, dead bacteria, cellular debris, and inflammatory cells, giving it its characteristic opaque, thick, and yellowish appearance.
Purulent drainage is a significant clinical finding that requires prompt attention and intervention. Early identification and management of wound infections can prevent complications such as abscess formation, cellulitis, sepsis, and delayed wound healing.
Accurate documentation of purulent drainage is essential for communication among healthcare providers, monitoring wound progress, and guiding treatment decisions.
Choice B rationale:
Serosanguineous drainage is a mixture of serous fluid (clear, thin, and watery) and blood. It often appears pink or slightly red and is commonly observed in the early stages of wound healing or after dressing changes. While it may contain a small amount of blood, it lacks the thick, creamy consistency and yellow color that are characteristic of purulent drainage.
Choice C rationale:
Serous drainage is clear, thin, and watery, resembling plasma. It is a normal part of the wound healing process and is often seen in the early inflammatory stage. It does not contain the thick consistency or yellow coloration that are indicative of purulent drainage.
Choice D rationale:
Sanguineous drainage is composed primarily of fresh blood. It is bright red in color and typically indicates active bleeding within the wound. It does not exhibit the thick, creamy consistency or yellow hue that are characteristic of purulent drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Secondary erythema refers to redness that develops after the initial injury or insult. It's not the most accurate term to describe an area that doesn't blanch, as blanching specifically assesses for the presence of blood in the tissue. Secondary erythema can be blanchable or nonblanchable, depending on the underlying cause.
Choice C rationale:
Blanchable hyperemia is a reddening of the skin that blanches (turns lighter) when pressed. This indicates that blood is still flowing to the area and that the tissue is not damaged. It's not the correct term for an area that doesn't blanch.
Choice D rationale:
Reactive hyperemia is a temporary increase in blood flow to an area that has been deprived of blood flow. It's often seen after pressure is relieved from a body part. While reactive hyperemia can cause redness, this redness typically blanches when pressed.
Choice B rationale:
Nonblanchable erythema is the most accurate term to describe an area of redness that does not turn lighter in color when pressed with a finger. This indicates that blood is not flowing to the area and that the tissue is likely damaged. Nonblanchable erythema is a significant finding because it can be a sign of a pressure injury (also known as a bedsore or pressure ulcer).
Key points about nonblanchable erythema:
It's a sign of impaired blood flow to the tissue. It's a potential indicator of a pressure injury.
It requires prompt assessment and intervention to prevent further tissue damage.
Correct Answer is C
Explanation
Choice A rationale:
Incorrect dosage form: Metformin is typically administered orally as a tablet or liquid suspension, not as a powder for reconstitution (PO).
Missing route of administration: The medication order does not specify the route of administration, such as oral (PO), intravenous (IV), or intramuscular (IM).
Potential for medication errors: The lack of clarity in the medication order could lead to errors in administration, such as giving the wrong dose or administering the medication by the wrong route.
Choice B rationale:
Incorrect dosage unit: Methotrexate is typically administered in milligrams (mg), not grams (g).
Potential for overdose: The order for 15.0 g of methotrexate is a very high dose that could lead to serious adverse effects, including toxicity and death.
Choice C rationale:
Correctly written: The medication order specifies the drug name (meropenem), the dose (1.0 g), the dosage form (IV), and the route of administration (IV).
Appropriate dosage range: The dose of 1.0 g of meropenem is within the typical dosage range for this antibiotic.
Clear and concise: The medication order is clear, concise, and easy to understand, which helps to reduce the risk of medication errors.
Choice D rationale:
Incorrect: While choices A and B are both incorrect, choice C is a correctly written medication order.
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