Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

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.

The correct answer is E(None of the Above)

Rationale for E:

The options A, B, C, and D all describe actions or physiological measurements that do not directly indicate an allergic reaction.

Allergic reactions involve the immune system's response to a specific substance, whereas side effects are unintended reactions to a medication that are not caused by an immune response.

Key differences between allergic reactions and side effects:

Allergic reactions:

Typically occur rapidly after exposure to the allergen.

Can involve various body systems, including the skin (hives, itching, rash), respiratory system (wheezing, difficulty breathing, throat tightness), gastrointestinal system (nausea, vomiting, diarrhea), and cardiovascular system (low blood pressure, shock).

May be life-threatening in severe cases, such as anaphylaxis. Side effects:

Can occur at any time during medication use.

Usually more predictable and less severe than allergic reactions.

Often subside as the body adjusts to the medication or with dose adjustments. Important considerations for nurses:

Carefully assess patients for potential allergies before administering medications.

Monitor patients closely for any signs of allergic reactions or side effects after medication administration.

Promptly intervene if an allergic reaction is suspected, following established protocols and administering emergency medications as needed.

Document all observations and actions related to medication administration and patient responses.