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?

Sanguineous

Serous

Serosanguineous

Purulent

Answer and Explanation

The Correct Answer is C

Choice A rationale
Sanguineous drainage is indicative of active bleeding and is typically bright red due to the presence of red blood cells. This type of drainage is not yellow-red and is not consistent with the description provided.

Choice B rationale
Serous drainage is clear and watery, and it is the fluid that is seen in blisters. It does not have a yellow-red color, so it does not match the description of the drainage observed.

Choice C rationale
Serosanguineous drainage is a mixture of serous and sanguineous drainage. It is typically light red or pink in color, which corresponds with the moist yellow-red stain described, indicating the presence of both plasma and red blood cells.
Choice D rationale
Purulent drainage is thick and opaque, usually yellow, green, or brown, and is associated with infection. The description of a yellow-red stain does not suggest that the drainage is purulent.

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Correct Answer is A

Explanation

Choice A rationale
The nurse’s first priority should always be to assess the patient’s condition. In the context of NPWT, this means checking for any complaints or problems in the wound area. This assessment helps to ensure that the NPWT is not causing additional issues and that the wound is healing as expected.

Choice B rationale
While it is important to check the settings on the NPWT unit to ensure it is functioning correctly, this is not the first priority. The patient’s well-being and response to treatment take precedence over equipment checks.

Choice C rationale
Documentation is a critical part of patient care, but it comes after patient assessment and any necessary interventions. It serves to record the patient’s status and the care provided but is not the immediate priority.

Choice D rationale
Observing the dressing area is part of the overall assessment of the patient and the effectiveness of the NPWT. However, it is not the first action to take. The nurse must first assess the patient for any discomfort or complications before focusing on the dressing itself.

A. Drawing the wound edges together using negative pressure. B. Strengthening the wall of the wound. C. Interrupting the proliferation of bacteria in the wound. D. Making and air occlusive cover for the wound

Correct Answer is A

Explanation

Choice A rationale
Vacuum-assisted closure (VAC) therapy aids in wound healing primarily by applying negative pressure to draw the wound edges together. This not only helps reduce the size of the wound but also promotes blood flow to the area, which can accelerate healing.

Choice B rationale
While VAC therapy does support the underlying structures of the wound, its primary function is not to strengthen the wall of the wound. The negative pressure assists in removing excess fluid and reducing edema, which indirectly supports the wound structure.

Choice C rationale
VAC therapy does have an impact on bacterial levels within the wound by helping to remove infectious materials. However, its main purpose is not to interrupt bacteria proliferation; this is more directly achieved through antibiotic therapy and proper wound care techniques.

Choice D rationale
While VAC does create a cover over the wound, its main purpose is to apply negative pressure to the wound area. This negative pressure helps to draw the wound edges together, promotes the removal of exudate and potentially infectious material, and stimulates the growth of new tissue, which aids in the healing process12. The occlusive cover is part of the system that allows the negative pressure to be maintained, but it is the negative pressure itself, not the cover, that provides the therapeutic benefit.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient is undergoing Negative Pressure Wound Therapy (NPWT) treatment for wound healing. Which would be your first priority in caring for this patient?

Correct Answer is A

Explanation

The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:

Correct Answer is A

Explanation

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