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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Canned soup is high in sodium due to preservatives, unsuitable for a low-sodium diet. Fresh, unprocessed foods are preferred, making this an incorrect recommendation for the client.
Choice B reason: Fresh apples are naturally low in sodium and align with a low-sodium diet. They provide nutrition without added salt, making them the correct food to recommend.
Choice C reason: Processed cheese contains high sodium levels for flavor and preservation, inappropriate for a low-sodium diet. Low-sodium alternatives are needed, making this incorrect.
Choice D reason: Pickles are high in sodium due to brining, contraindicated for a low-sodium diet. Fresh fruits like apples are better choices, making pickles an incorrect recommendation.
Correct Answer is B
Explanation
Choice A reason: Observing the cardiac monitor for an increased heart rate can suggest pain but is not specific, as tachycardia may result from anxiety or hypovolemia. Directly assessing the patient’s reported pain level using a standardized scale provides precise, subjective data to guide analgesia, making this a less priority.
Choice B reason: Asking the patient to rate their pain level is the priority, as it a quantifies their subjective experience (e.g., 0-10 scale), guiding pain management decisions. This patient-centered approach ensures timely, tailored intervention, addressing the complaint directly and informing subsequent actions like inspection or medication administration, making it the most critical step.
Choice C reason: Assessing body language offers nonverbal pain cues, but it is less reliable than a verbal pain rating. Nonverbal signs can be misinterpreted, and cultural factors may influence expression, making this a secondary assessment. Subjective pain rating provides clearer, actionable data, prioritizing it over observational cues.
Choice D reason: Inspecting the incision site is important for detecting complications (e.g., infection, dehiscence), but pain assessment precedes it. A patient’s reported pain level determines the urgency of further evaluation or intervention, making inspection a follow-up action rather than the initial priority when addressing postoperative pain complaints.
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