A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

Sanguineous.

Serous.

Purulent.

Serosanguineous.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.

Choice B rationale:

Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.

Choice C rationale:

Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.

Choice D rationale:

Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.

Choice B rationale:

Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.

Choice C rationale:

Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.

Choice D rationale:

Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.

A. Ask the patient why this medication has been ordered. B. Verify with the hospital administration the reason for the medication. C. Verify with the prescribing healthcare provider the reason for the medication. D. Ask another nurse why the patient is getting this medication.

Correct Answer is C

Explanation

Choice A rationale:

Asking the patient why this medication has been ordered is not the appropriate action because patients might not have accurate medical knowledge to provide a valid explanation for the prescription. The nurse should rely on healthcare professionals for accurate information.

Choice B rationale:

Verifying with the hospital administration is not necessary in this situation. The decision to prescribe medication is made by the healthcare provider, not the hospital administration.

Choice C rationale:

Verifying with the prescribing healthcare provider is the most appropriate action. The healthcare provider has the medical knowledge and rationale for prescribing a specific medication. This ensures that the nurse administers the medication safely and in alignment with the patient's condition and treatment plan.

Choice D rationale:

Asking another nurse might not yield accurate information about the rationale behind the medication order. It's best to directly communicate with the healthcare provider responsible for the patient's care.

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A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

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Naxlex Comprehensive Predictor Exams

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