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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D - "Eating a high fiber diet will reduce my risk for developing skin cancer."

Choice A rationale:

Checking the skin monthly for any changes is a recommended practice for early detection of skin cancer. Changes in the size, color, shape, or appearance of moles or spots can be indicative of skin cancer. This statement demonstrates understanding and does not require further teaching.

Choice B rationale:

Avoiding the use of tanning booths is a crucial recommendation for preventing skin cancer. Tanning booths emit ultraviolet (UV) radiation, which significantly increases the risk of skin cancer. This statement reflects accurate knowledge and does not indicate a need for further teaching.

Choice C rationale:

Using sunscreen even on cloudy days is a sound practice to prevent skin cancer. UV rays can penetrate clouds and cause skin damage even when the sun is not directly visible. This statement shows good understanding and does not require further teaching.

Choice D rationale:

Eating a high fiber diet will reduce my risk for developing skin cancer - This statement indicates a need for further teaching. While a high fiber diet has various health benefits, it is not directly linked to reducing the risk of developing skin cancer. Skin cancer prevention primarily involves sun protection measures, avoiding tanning beds, and regular skin checks. The nurse should clarify the correct strategies for preventing skin cancer.

A. Reposition the client every 3 hours. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

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