A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?
Purulent
Serous
Sanguineous
Hyperemia
The Correct Answer is C
A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
Correct Answer is ["B","C","D","E"]
Explanation
A. Eye exams are generally recommended more frequently, especially for older adults, to monitor for age-related changes and conditions.
B. Women should have a clinical breast examination every year, in addition to mammograms as recommended by their healthcare provider.
C. Both men and women should have a colonoscopy periodically, depending on individual risk factors and age.
D. Regular hearing screenings are important for older adults, especially as age-related hearing loss may occur.
E. Testicular self-exams are recommended for men to detect any abnormalities early on.
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