When changing the dressing on the patient’s right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?

Choice A rationale

A contusion, commonly known as a bruise, is characterized by skin discoloration due to trauma that causes bleeding under the skin. It does not result in a raised scar, which is why it is not the correct term to describe the patient's condition.

Choice B rationale

A keloid is an overgrowth of scar tissue that forms at the site of a healed skin injury. Keloids are more common in people with darker skin tones, such as African Americans, and are characterized by a raised, firm, and sometimes itchy or painful scar that extends beyond the original wound boundaries. This description matches the nurse's assessment of the patient's scar.

Choice C rationale

A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse is assessing a scar, not a fresh wound, laceration is not the appropriate term for documentation.

Choice D rationale

A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This term would not be used to describe a raised scar, making it an incorrect choice for documentation.

Choice A rationale
Preparing a discard bag next to the wound is a practical step in the process, but it is not the most critical action to prevent infection.

Choice B rationale
Remaining very still during the procedure is important, but it does not directly relate to maintaining the sterility of the dressing change.

Choice C rationale
Restraining from moving the patient is not typically necessary unless the patient is at risk of causing harm to themselves or disrupting the procedure.

Choice D rationale
Changing gloves after removing the old dressing is crucial to maintain sterility. The old dressing may be contaminated, and fresh gloves reduce the risk of introducing bacteria to the clean wound.