A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?
Serous
Purulent
Serosanguineous
Sanguineous
The Correct Answer is A
Rationale:
A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.
B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.
C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.
D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.
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Correct Answer is A
Explanation
Rationale:
A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.
B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.
C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.
D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.
Correct Answer is C
Explanation
Rationale:
A. Limiting activity can contribute to constipation, so the nurse should encourage regular physical activity to promote bowel function.
B. Drinking four to five glasses of water daily is insufficient; older adults typically need at least 6-8 glasses to help prevent constipation.
C. Increasing dietary intake of raw vegetables provides fiber, which is essential for promoting bowel regularity and preventing constipation. This recommendation aligns with dietary guidelines for improving gastrointestinal health.
D. Bearing down hard when defecating can lead to complications such as hemorrhoids or valsalva maneuvers, so clients should be taught to relax and allow for a natural bowel movement instead.