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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 A

Explanation

Choice A rationale: Wet-to-dry dressings are a form of mechanical debridement. This method involves applying a wet dressing to the wound and allowing it to dry. When the dressing is removed, it also removes some of the dead or damaged tissue from the wound, helping to clean the wound and promote healing. This method can be painful and is not selective, meaning it can also remove healthy tissue. However, it is often used for wounds with a large amount of debris or necrotic tissue.

Choice B rationale: Surgical debridement is another method of wound debridement, but it is not a form of mechanical debridement. This method involves using surgical instruments to remove dead or damaged tissue. It is the fastest method of debridement and is often used for wounds that are infected or have a large amount of necrotic tissue. However, it requires a skilled practitioner and can be painful.

Choice C rationale: Enzymatic debridement involves applying a topical ointment that contains enzymes to the wound. These enzymes help to break down dead or damaged tissue. This method is selective and only removes necrotic tissue, leaving healthy tissue intact. However, it is not a form of mechanical debridement.

Choice D rationale: Autolytic debridement is a method that uses the body’s own enzymes and moisture to break down dead or damaged tissue. This is the slowest method of debridement but is also the least painful and is selective for necrotic tissue. Like enzymatic debridement, autolytic debridement is not a form of mechanical debridement.

A. Chill the irrigant prior to the procedure. B. Irrigate the wound until the solution that is draining is clean. C. Hold the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating. D. Flush the wound from the most contaminated area to the cleanest area.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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