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

Serosanguineous

Serous

Purulent

Answer and Explanation

The Correct Answer is B

A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.

B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.

C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.

D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.

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Correct Answer is D

Explanation

A. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.

B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.

C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.

D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.

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 watery red drainage. The nurse should document this drainage as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a new colostomy, and had a bowel preparation before surgery. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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