Nokea
What technique will the nurse implement to assist the postoperative patient to cough?
- A. Support the patient's back.
- B. Offer an antitussive.
- C. Splint the abdomen with a pillow.
- D. Lean patient against the bedside table.
Correct Answer: C
Rationale: To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.
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The nurse encourages a patient recovering from a hysterectomy to drink at least ___ mL of fluid a day.
Correct Answer: 2000
Rationale: A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily.
The nurse assessing a patient's wound notes pale red watery drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: D
Rationale: Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding.
The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
- A. 50 mL
- B. 100 mL
- C. 200 mL
- D. 300 mL
Correct Answer: D
Rationale: Drainage greater than 300 mL in 24 hours is considered abnormal.
The nurse assessing a patient's wound notes thick yellow drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: B
Rationale: Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage.
The nurse assures a patient that the purple raised immature scar of a surgical wound is normal and caused by ___ formation.
Correct Answer: collagen
Rationale: Collagen forms as an immature scar over a new surgical wound.