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

Answer and Explanation

The Correct Answer is C

Choice A reason: Sanguineous drainage is bright red and consists primarily of blood, indicating active bleeding. Watery red drainage suggests a mix of blood and serous fluid, not pure blood, making this choice incorrect for the described wound drainage.

Choice B reason: Serous drainage is clear or slightly yellow, watery fluid without blood. The presence of red in the described watery drainage indicates a combination with blood, ruling out pure serous drainage, making this choice incorrect for the observed characteristics.

Choice C reason: Serosanguineous drainage is watery, pink to light red, combining serous fluid and blood. This matches the described watery red drainage, typical in healing wounds with minor bleeding, making it the correct documentation term for the nurse to use.

Choice D reason: Purulent drainage is thick, opaque, and often yellow, green, or white, indicating infection. Watery red drainage does not fit this description, as it lacks the viscosity and color of pus, making this an incorrect choice for the wound’s drainage.

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Correct Answer is B

Explanation

Choice A reason: A newly admitted client needing wet-to-dry dressing changes requires initial wound assessment and teaching, which are RN responsibilities. LPNs can perform dressings, but new admissions involve complex evaluations outside their scope, making this inappropriate for delegation.

Choice B reason: Emptying a JP drain for a discharge-ready client is a routine, stable task within an LPN’s scope. The patient’s condition is stable, and the procedure is straightforward, requiring no complex judgment, making this the most appropriate task to delegate to an LPN/LVN.

Choice C reason: A client with a stage III pressure ulcer and IV antibiotics requires advanced wound assessment and IV management, which are RN tasks. LPNs have limited scope for IV therapy and complex wounds, making this inappropriate for delegation.

Choice D reason: A client 2 days post-abdominal surgery on oral pain medication may need monitoring for complications, an RN responsibility. LPNs can assist, but potential instability makes this less suitable for delegation compared to the stable, routine task of emptying a JP drain.

A. A 24-year-old adult admitted for chronic alcohol abuse B. A 75-year-old patient admitted for a broken hip related to osteoporosis C. A 50-year-old patient admitted for acute hyperparathyroidism D. A 7-year-old child admitted for severe burns

Correct Answer is C

Explanation

Choice A reason: Chronic alcohol abuse may cause hypomagnesemia, which can mimic hypocalcemia symptoms, but a positive Chvostek sign is specific to low calcium. Alcoholism alone is less likely to cause this sign without concurrent hypocalcemia, making this choice incorrect.

Choice B reason: Osteoporosis in a 75-year-old involves bone density loss but does not typically cause hypocalcemia or a positive Chvostek sign. Calcium levels are usually normal unless other conditions exist, making this choice incorrect for the expected finding.

Choice C reason: Acute hyperparathyroidism can lead to hypocalcemia after parathyroidectomy or in secondary complications, causing a positive Chvostek sign (facial twitching when tapping the facial nerve). Low calcium triggers this neuromuscular response, making this the correct choice.

Choice D reason: Severe burns cause fluid shifts and potential electrolyte imbalances, but hypocalcemia is not a primary feature. A positive Chvostek sign is less likely without specific calcium depletion, making this choice incorrect for the expected finding.

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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

Which of the following clients is most appropriate to delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)?

Correct Answer is B

Explanation

In which patient will the nurse expect to see a positive Chvostek sign?

Correct Answer is C

Explanation

Which of the following interventions should be included in the plan of care for a client who has a prescription for a clear liquid diet? (Select all that apply)

Which patient using an inhaler would benefit most from using a spacer?

Which patient is most at risk for pressure ulcer formation?

A nurse is planning care for a client who has returned to the unit following a surgical procedure. The client’s oxygen saturation is 88%. Which of the following actions should the nurse take first?

A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

A nurse is teaching a client who has a new prescription for warfarin about medication interactions. Which of the following medications should the nurse instruct the client to avoid?

A nurse is removing staples from a client’s surgical incision. Which of the following will ensure safe removal? (Select all that apply)

A nurse is preparing to administer an IV push medication to a client. Which of the following actions should the nurse take?