A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

Choice A rationale

Sterile gloves are not necessary when checking a patient’s pulse. They are typically used for procedures that require aseptic technique, such as wound dressing changes or insertion of a central venous catheter.

Choice B rationale

Protective eyewear is used to protect the healthcare provider from splashes or sprays of blood, body fluids, secretions, or excretions. It is not necessary when checking a patient’s pulse.

Choice C rationale

Clean gloves should be worn when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. This includes when caring for a patient with MRSA in an abdominal wound.

Choice D rationale

An N95 respirator mask is used to protect the healthcare provider from airborne pathogens, such as tuberculosis. It is not necessary when checking a patient’s pulse.

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.