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","B","C"]
Explanation
The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.
A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.
Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.
Correct Answer is D
Explanation
A. Vitamin D is important for bone health but is not directly involved in wound healing.
B. Vitamin B1 (thiamine) is essential for energy metabolism but does not play a major role in wound healing.
C. Calcium is vital for bone health, but protein plays a more significant role in tissue repair.
D. Protein is essential for tissue regeneration and wound healing as it helps build and repair tissues.
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