A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?
Sanguineous.
Serous.
Purulent.
Serosanguineous.
The Correct Answer is D
Choice A rationale:
Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.
Choice B rationale:
Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.
Choice C rationale:
Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.
Choice D rationale:
Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.
Choice B rationale:
Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.
Choice C rationale:
Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.
Choice D rationale:
Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.
Correct Answer is C
Explanation
Choice A rationale:
Justice. Justice refers to fair and equitable treatment for all individuals. While it is an important ethical principle, it does not directly relate to the nurse's action of returning a telephone call promptly and as promised. Justice involves issues of fairness and distribution of resources, and it's not the most applicable principle in this context.
Choice B rationale:
Nonmaleficence. Nonmaleficence refers to the principle of "do no harm." While it is crucial in healthcare, it doesn't directly address the nurse's action of returning a client's call promptly. This principle is more concerned with preventing harm in clinical interventions and decision-making.
Choice C rationale:
Fidelity. Fidelity, or faithfulness, is the ethical principle that aligns with the nurse's action in this scenario. By returning the call by the end of the day as promised, the nurse is demonstrating fidelity to the client's trust and expectations. This principle emphasizes the importance of keeping promises and being loyal to commitments made to clients.
Choice D rationale:
Autonomy. Autonomy pertains to an individual's right to make their own decisions about their care and treatment. While autonomy is a vital principle in healthcare, it does not directly relate to the nurse's action of returning a telephone call promptly. Autonomy focuses more on involving the client in their care decisions and respecting their choices.
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