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A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

Purulent.

Sanguineous.

Serosanguineous.

Serous.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Purulent drainage is thick and opaque. It can have a yellow, tan, green, or brown color and is a sign of infection.

Choice B rationale

Sanguineous drainage is bright red and indicates active bleeding3.

Choice C rationale

Serosanguineous drainage is typically pink-red and thin. It is made up of blood and serous fluid and is typically seen in a normal, non-infected wound3.

Choice D rationale

Serous drainage is clear and thin, like the fluid from a blister3.

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Correct Answer is B

Explanation

Choice A rationale

Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.

Choice B rationale

Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.

Choice C rationale

Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.

Choice D rationale

Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.

A. Emptying the drainage bag when half full. B. Placing the drainage bag on the side rail of the patient’s bed. C. Kinking the catheter tubing to obtain a urine specimen. D. Securing the catheter tubing to the patient’s thigh.

Correct Answer is B

Explanation

Choice A rationale

Emptying the drainage bag when half full is a correct action by the AP4. It is important to empty the drainage bag regularly to prevent infection and maintain accurate intake and output records.

Choice B rationale

Placing the drainage bag on the side rail of the patient’s bed is an incorrect action by the AP4. The drainage bag should be placed below the level of the bladder to prevent backflow of urine, which can lead to infection.

Choice C rationale

Kinking the catheter tubing to obtain a urine specimen is an incorrect action by the AP4. This can cause discomfort to the patient and potentially damage the catheter.

Choice D rationale

Securing the catheter tubing to the patient’s thigh is a correct action by the AP4. This helps to prevent pulling on the catheter, which can cause discomfort and potential damage to the urethra.

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A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to irrigate a wound for a patient. What actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is evaluating a nursing assistive personnel’s (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

Correct Answer is B

Explanation

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