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

The correct answer is Choice A.

Choice A rationale:

Tetanus is an acute infectious disease caused by spores of the bacterium Clostridium tetani.The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, barbed wire, etc.Anyone can get tetanus, but the disease is particularly common and serious in newborn babies and pregnant women who have not been sufficiently immunized with tetanus-toxoid-containing vaccines.

To ensure that there is adequate antitoxin to neutralize tetanus toxin in the case of a tetanus-prone injury, a booster dose is advised if it has been longer than 10 years since the last tetanus vaccine dose.This is because a single dose of tetanus toxoid produces a rapid anamnestic response. Therefore, if a patient with a puncture wound has not received a tetanus toxoid vaccination in the last 10 years, they would require an additional injection before being discharged from the emergency department.

Choice B rationale:

While it might seem prudent to administer a tetanus toxoid vaccination every year, this is not necessary according to current medical guidelines.Over-vaccination could potentially lead to an increased risk of adverse reactions without providing additional benefits. Therefore, a tetanus toxoid vaccination is not required every year.

Choice C rationale:

A 5-year interval for tetanus toxoid vaccination is not the standard recommendation for general population.However, in some specific cases, such as when indicated for wound management, a tetanus toxoid–containing vaccine might be administered if ≥5 years have elapsed since the previous receipt of any tetanus toxoid–containing vaccine.

Choice D rationale:

A 2-year interval for tetanus toxoid vaccination is not the standard recommendation.The tetanus toxoid vaccination provides protection for a much longer period, and therefore, it is not necessary to administer the vaccine every 2 years.

A. 20 mL B. 5 mL C. 10 mL D. 15 mL

Correct Answer is C

Explanation

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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

The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

Correct Answer is A

Explanation

The nurse is to administer 10 mg/kg of acetaminophen to a patient who weighs 70 pounds (32 kg). The acetaminophen elixir is 160 mg per 5 mL. How many mL of medication will be given to the patient for each dose?

Correct Answer is C

Explanation

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