A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Sanguineous

Serous

Serosanguineous

Purulent

Answer and Explanation

The Correct Answer is C

A. Sanguineous drainage consists mostly of blood and is bright red, indicating active bleeding.

B. Serous drainage is clear or slightly yellowish and watery, often seen in healing wounds.

C. Serosanguineous drainage is a mixture of blood and serous fluid, which is watery with a pink or reddish tinge, common in early wound healing.

D. Purulent drainage is thick and cloudy, indicating infection, usually accompanied by an unpleasant odor.

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Correct Answer is C

Explanation

A. Massaging red bony prominences may cause further skin damage and increase the risk of pressure ulcers.

B. Skin should be assessed for warmth, redness, and integrity, but coolness is not necessarily an indicator of pressure injury.

C. Repositioning every 2 hours is essential for preventing pressure ulcers in bed-bound clients by relieving pressure on vulnerable areas.

D. Keeping the skin moist increases the risk of skin breakdown. It is important to keep the skin dry and clean.

A. Immediately before the client has a meal B. After the client feels abdominal cramping C. Every 2 hr while the client is awake D. When the client has the urge to defecate

Correct Answer is D

Explanation

A. Taking the client to the toilet immediately before a meal does not correlate with the natural timing of defecation.

B. Abdominal cramping may indicate constipation or other issues, but waiting for cramping is not part of bowel training.

C. Taking the client to the toilet every 2 hours may not align with the client’s natural bowel habits.

D. The goal of bowel training is to help the client recognize and respond to the urge to defecate, promoting regular bowel habits and reducing incontinence.

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A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

Correct Answer is D

Explanation

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?

A nurse is teaching a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

Which of the following is a common risk factor for developing a urinary tract infection (UTI)?

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?