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 D

Explanation

A. Telling the patient to close their eyes may not alleviate their anxiety and does not provide comfort or education.

B. Asking the family to leave could increase the patient's anxiety, especially if the family provides emotional support.

C. Turning on the television may distract the patient, but it doesn't address their anxiety.

D. Explaining the procedure helps reduce anxiety by informing the patient about what to expect, which promotes trust and understanding.

A. Elevate the head of the bed no more than 45°. B. Apply baby powder to keep sensitive skin areas dry. C. Lift, rather than pull, to lift the client up in bed. D. Massage the reddened skin over the client's bony prominences.

Correct Answer is C

Explanation

A. The head of the bed should be elevated no more than 30° to prevent shearing forces on the skin.

B. Baby powder can cause dryness and irritation rather than protecting the skin.

C. Lifting rather than pulling reduces the risk of friction and shearing forces, which can lead to skin breakdown and pressure ulcers.

D. Massaging reddened skin over bony prominences can damage already compromised tissue and increase the risk of pressure ulcers.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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