A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?
Sanguineous
Serous
Serosanguineous
Purulent
The Correct Answer is C
A. Sanguineous drainage consists mostly of blood and is bright red, indicating active bleeding.
B. Serous drainage is clear or slightly yellowish and watery, often seen in healing wounds.
C. Serosanguineous drainage is a mixture of blood and serous fluid, which is watery with a pink or reddish tinge, common in early wound healing.
D. Purulent drainage is thick and cloudy, indicating infection, usually accompanied by an unpleasant odor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Massaging red bony prominences may cause further skin damage and increase the risk of pressure ulcers.
B. Skin should be assessed for warmth, redness, and integrity, but coolness is not necessarily an indicator of pressure injury.
C. Repositioning every 2 hours is essential for preventing pressure ulcers in bed-bound clients by relieving pressure on vulnerable areas.
D. Keeping the skin moist increases the risk of skin breakdown. It is important to keep the skin dry and clean.
Correct Answer is C
Explanation
A. Abdominal distention may indicate that peristalsis has not yet returned.
B. A request for food may indicate hunger but is not a reliable indicator that peristalsis has returned.
C. Passage of flatus is a clear sign that peristalsis is returning as it shows that the intestines are moving contents.
D. Hypoactive bowel sounds suggest slow or minimal peristaltic activity and are not a sign that peristalsis is fully returning.
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