A nurse observes drainage that is pale pink and watery. How should this be documented?
Sanguineous drainage.
Serosanguineous drainage
Purulent drainage
Serous drainage
The Correct Answer is B
A. Sanguineous drainage: Sanguineous drainage is fresh, bright red blood.
B. Serosanguineous drainage: Serosanguineous drainage is a mixture of serous fluid (pale, watery) and sanguineous fluid (blood), resulting in a thin, watery, pale pink or light red color. This is a common, normal finding in the inflammatory and proliferative phases of healing.
C. Purulent drainage: Purulent drainage is thick, opaque, and colored (yellow, green, or brown) with a foul odor, indicative of infection.
D. Serous drainage: Serous drainage is clear, thin, and watery, like plasma. The presence of a pink tint indicates blood, classifying it as serosanguineous.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Apply a warm compress to the area to improve circulation: Applying heat can increase the metabolic demands of the already compromised tissue, potentially worsening the injury.
B. Document the finding and recheck in 24 hours: A Stage 1 pressure injury requires immediate action to relieve pressure to prevent progression. Delaying intervention for 24 hours can allow the injury to worsen.
C. Massage the area gently to promote blood flow:Massaging a reddened, nonblanching area can intensify the underlying capillary and tissue damage, leading to further tissue necrosis and progression to a deeper stage.
D. Reposition the patient to relieve pressure on the heel: The nonblanchable erythema signifies deep tissue ischemia caused by unrelieved pressure. The most appropriate and critical nursing action is to eliminate the pressure immediately by repositioning the patient so the bony prominence is no longer compressed. This is the only way to reverse the ischemia.
Correct Answer is D
Explanation
A. High dietary protein intake: Adequate protein intake is essential for wound healing. High protein intake would generally be beneficial, not detrimental, to wound repair.
B. Regular exercise: Regular, appropriate exercise generally improves circulation and is beneficial for overall health and wound healing.
C. Excessive vitamin C: Vitamin C (ascorbic acid) is necessary for collagen synthesis and is generally beneficial for wound healing. Excessive intake is rarely a direct cause of wound ischemia.
D. Peripheral artery disease: Peripheral artery disease (PAD) is a common macrovascular complication of diabetes where blood vessels narrow, leading to severely reduced blood flow (ischemia) to the lower extremities. Without adequate perfusion, the wound cannot receive the oxygen, nutrients, and immune cells required for healing, making ischemia the most likely contributing factor to a non-healing diabetic foot ulcer.
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