A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?

Serous

Purulent

Serosanguineous

Sanguineous

Answer and Explanation

The Correct Answer is A

A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.

B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.

C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.

D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.

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Correct Answer is C

Explanation

A. A wet-to-dry dressing is typically used for debridement and is not appropriate for a shallow pressure ulcer without necrotic tissue, as it can damage healthy tissue during dressing changes.

B. Leaving the area without a dressing is not advisable as it exposes the wound to contaminants and increases the risk of infection; a dressing should be used to protect the area.

C. A hydrocolloid dressing is ideal for shallow partial-thickness wounds as it provides a moist environment, promotes healing, and helps to cushion the area while maintaining a barrier against bacteria.

D. Alginate dressings are primarily used for wounds with moderate to heavy exudate and would not be suitable in this case due to the lack of drainage.

A. "You can expect fecal output within 24 hours" B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week" D. "You may experience a small amount of bleeding around the stoma"

Correct Answer is D

Explanation

A. After a bowel preparation, it typically takes a few days for fecal output to occur from the new colostomy due to the emptying of the bowel before surgery.

B. Increasing raw vegetables immediately after surgery is not recommended, as they can cause gas and irritation to the bowel. Clients are usually advised to start with low-fiber foods and gradually introduce more fiber.

C. A healthy stoma should be pink to red in color. A purplish color may indicate compromised blood flow and should be reported to the healthcare provider.

D. A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the appliance, as the tissue is delicate and highly vascular.

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A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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