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

Purulent.

Serous.

Sanguinous.

Serosanguineous.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.

Choice B rationale:

Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.

Choice C rationale:

Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.

Choice D rationale:

Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.

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Correct Answer is A

Explanation

Choice A rationale:

Dakin solution is used for chemical debridement of a wound.

Choice B rationale:

Primary intention is a method of wound healing, not a result of Dakin solution.

Choice C rationale:

While Dakin solution can aid in wound healing, it does not directly cause healing.

Choice D rationale:

Phagocytosis is a process carried out by certain cells in the body, not a result of Dakin solution.

A. Stage 1. B. Stage 3. C. Stage 2. D. Stage 4.

Correct Answer is C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

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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. You would document this as drainage.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse places Dakin solution in a wound to accomplish chemical:

Correct Answer is A

Explanation

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal.The nurse would change the dressing procedure in order to use:

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?