A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.The nurse should identify which of the following findings as indicative of an infection?
Milky fluid.
Bloody fluid.
Viscous fluid.
Purulent fluid.
The Correct Answer is D
Choice A rationale
Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.
Choice B rationale
Bloody fluid may indicate trauma or malignancy but not necessarily infection.
Choice C rationale
Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.
Choice D rationale
Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
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Correct Answer is C
Explanation
Choice A rationale
Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.
Choice B rationale
Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.
Choice C rationale
Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.
Choice D rationale
Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.
Correct Answer is D
Explanation
Choice A rationale
Metabolic acidosis is characterized by a low pH and decreased HCO₃ levels, not increased PaCO₂.
Choice B rationale
Metabolic alkalosis presents with an elevated pH and increased HCO₃ levels, which do not match the given values.
Choice C rationale
Respiratory alkalosis is indicated by a high pH and decreased PaCO₂, opposite of the provided values.
Choice D rationale
Respiratory acidosis is identified by a low pH, elevated PaCO₂, and normal HCO₃, aligning with the provided values.