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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This choice is correct. Hepatitis B is primarily transmitted through contact with infected blood and bodily fluids. Contact precautions are designed to prevent the spread of infections that are transmitted through direct or indirect contact. These precautions include wearing gloves and gowns when in contact with the client or their environment.
Choice B rationale:
Droplet precautions are not appropriate for hepatitis B. Droplet precautions are used for infections that are spread through respiratory droplets, like coughing or sneezing. Hepatitis B is not primarily transmitted through respiratory droplets.
Choice C rationale:
Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and eye protection to prevent the transmission of infections. While these precautions should always be practiced, they are not specifically tailored to hepatitis B, which has its own set of precautions.
Choice D rationale:
Airborne precautions are used for infections that are spread through small respiratory particles that remain suspended in the air for longer periods. Hepatitis B is not transmitted through airborne routes, so airborne precautions are not necessary.
Correct Answer is C
Explanation
Choice A rationale:
Lillian Wald is known for founding the Henry Street Settlement in New York and for her work in public health nursing and social reform, but she is not specifically associated with keeping records on sanitation techniques and their effects on health.
Choice B rationale:
Clara Barton is renowned for establishing the American Red Cross and her humanitarian efforts during the Civil War. While she contributed significantly to healthcare, her focus was not on keeping records on sanitation techniques and their effects.
Choice C rationale:
Florence Nightingale, the founder of modern nursing, is the nurse who kept records on sanitation techniques and their effects on health. She is known for her work during the Crimean War, where she improved sanitation and hygiene practices in healthcare settings, leading to significant improvements in patient outcomes.
Choice D rationale:
Mary Nutting was an influential figure in nursing education, but she is not primarily recognized for keeping records on sanitation techniques and their effects. Her contributions were more related to curriculum development and nursing education.
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