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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Hemorrhoids are swollen veins in the anus and rectum that can cause pain, itching, and bleeding. Sitz baths are a common and effective treatment for hemorrhoids because they can help to:

Reduce inflammation and pain Promote healing

Relax the anal sphincter muscles Cleanse the anal area

Warm water helps to increase blood flow to the area, which can help to reduce swelling and inflammation. The water also helps to soothe and cleanse the irritated tissues.

Sitz baths are typically taken for 10-15 minutes at a time, several times a day. They can be taken in a bathtub or a special sitz bath basin that fits over a toilet seat.

Choice B rationale:

A fractured right arm would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice C rationale:

An abscessed tooth would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice D rationale:

Painful back muscle spasms would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

A. The nurse aspirates immediately prior to injecting the medication. B. The nurse gently massages the injection site immediately afterward. C. The nurse draws up the medication into a 1-mL syringe with a 32-gauge needle. D. The nurse injects the medication into the soft tissue of the patient’s abdomen.

Correct Answer is D

Explanation

Choice A rationale:

Aspirating prior to injecting enoxaparin is not recommended.

Aspiration was once a common practice to check if a needle had entered a blood vessel.

However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation.

Additionally, aspirating can increase the risk of needlestick injuries.

For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.

Choice B rationale:

Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation.

It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding.

The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.

Choice C rationale:

The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections.

This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.

Choice D rationale:

The abdomen is the preferred site for subcutaneous injections of enoxaparin.

The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication.

The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks.

However, the abdomen is generally the preferred site.

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How should a nurse document the presence of thick, creamy yellow discharge on a patient’s dressing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient would most likely benefit from a sitz bath?

Correct Answer is A

Explanation

The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct?

Correct Answer is D

Explanation

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