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 B

Explanation

A. Autonomy:This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.

B. Veracity:This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.

C. Confidentiality:This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.

D. Beneficence:This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.

A. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained. B. The primary health care provider tells a client that the nurse "does not know anything.” C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around. D. The nurse tells a client that he will be tied down if he tries to get up from the chair.

Correct Answer is A

Explanation

Choice A rationale:

This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.

Choice B rationale:

While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.

Choice C rationale:

Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.

Choice D rationale:

Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?

Correct Answer is A

Explanation

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