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

Answer and Explanation

The Correct Answer is A

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 C

Explanation

A. Although the adolescent in a halo brace has some immobility, the greatest risk factors for skin breakdown involve areas where prolonged pressure is applied, and older adults are more vulnerable due to age-related skin changes.

B. A fractured radius and arm cast do not pose a significant risk for skin breakdown because the client can still mobilize and reposition themselves, reducing prolonged pressure.

C. An older adult with a hip fracture in Buck's traction is at greatest risk for skin breakdown due to immobility, pressure from the traction setup, and the reduced skin elasticity and healing capacity that come with age.

D. While skeletal balanced suspension traction poses some risk, a young adult typically has better skin integrity and mobility than an older adult, reducing the risk for skin breakdown.

A. Remind the client he might feel a constant urge to void. B. Weigh the client every evening. C. Monitor the client's urine output every 6 hr. D. Restrict the client's oral fluid intake.

Correct Answer is A

Explanation

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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