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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Docusate sodium is a stool softener, and it may take 1-3 days to produce a bowel movement, so this statement reflects proper understanding.
B. Docusate is used to prevent constipation, not treat diarrhea, so this statement is incorrect.
C. Taking docusate sodium with mineral oil can increase the risk of absorption of mineral oil into the system, which is harmful, so this combination should be avoided.
D. The client should drink plenty of fluids, around 8 ounces or more, to help soften the stool.
Correct Answer is ["D","E"]
Explanation
A. Using powder can cause skin irritation and dryness and is not recommended for preventing skin breakdown.
B. Clients should be repositioned at least every 2 hours, not every 4 hours, to prevent pressure ulcers.
C. Massaging over erythematous areas can damage fragile tissue and increase the risk of skin breakdown.
D. Using pillows to keep heels off the bed surface helps relieve pressure on bony prominences, reducing the risk of pressure ulcers.
E. Minimizing skin exposure to moisture prevents maceration and skin breakdown, especially in incontinent clients.
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