The client tells the nurse that clear fluid is seeping out of a blister on the arm. The nurse describes this type of fluid as which of the following?
Purulent fluid
Hemorrhagic fluid
Serosanguineous fluid
Serous fluid
The Correct Answer is D
Rationale:
A. Purulent fluid is thick, opaque, and often yellow, green, or brown in color. It contains leukocytes, cellular debris, and bacteria, and is typically associated with infection. Because purulent fluid is not clear, it does not match the description provided by the client.
B. Hemorrhagic fluid contains blood. It appears red or dark red due to the presence of red blood cells and indicates bleeding into a wound or blister. Hemorrhagic fluid is not clear, so it does not correspond to the fluid described.
C. Serosanguineous fluid is a mixture of clear (serous) fluid and small amounts of blood, giving it a pale pink or light red appearance. While it is partially clear, the presence of blood changes its color, making it different from completely clear fluid.
D. Serous fluid is a clear, watery fluid that is typically seen in blisters caused by friction or minor burns. It is composed mainly of plasma and electrolytes and functions to cushion and protect underlying tissues. The fluid described by the client as “clear” corresponds to serous fluid, making it the correct classification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Thrombocytosis refers to an elevated platelet count, which can increase the risk of clot formation. It is unrelated to white blood cells and does not indicate infection or inflammation.
B. Neutropenia is a decreased number of neutrophils, a type of white blood cell, which can increase susceptibility to infections. This term represents a deficiency rather than an increase in white blood cells.
C. Anemia refers to a reduced number of red blood cells or decreased hemoglobin, leading to impaired oxygen delivery. It is unrelated to white blood cell counts or immune response.
D. Leukocytosis is defined as an increase in the total number of white blood cells (leukocytes), often in response to infection, inflammation, stress, or certain hematologic disorders. This increase is part of the body’s immune response, helping to fight pathogens and promote healing.
Correct Answer is D
Explanation
Rationale:
A. The rule of nines is a method for calculating gestational age during pregnancy is incorrect. Gestational age is determined using methods such as the last menstrual period, early ultrasound measurements, or fetal biometry, which assess fetal growth and development. The rule of nines has no role in obstetrics and does not provide any information about pregnancy duration or fetal maturity.
B. The rule of nines is used to determine the ideal body weight based on height and weight calculations is incorrect. Ideal body weight calculations rely on formulas like the Devine or Hamwi equations, which consider height, sex, and sometimes body frame size. The rule of nines does not involve body weight, body mass index, or nutritional assessment, so it cannot be used for this purpose.
C. The rule of nines is used to estimate burn depth and healing potential of a burn wound is partially incorrect. While assessing burn depth and healing potential is important in burn care, the rule of nines specifically addresses only the total body surface area (TBSA) affected by burns. Burn depth is evaluated separately by examining skin layers involved, color, sensation, and tissue viability. Therefore, this statement inaccurately conflates burn depth assessment with the TBSA estimation function of the rule of nines.
D. The rule of nines divides the body into multiples of nine to estimate the percentage of total body surface area burned is correct. In adults, the body is divided into regions representing roughly 9% or multiples of 9% of TBSA, including the head and neck (9%), each arm (9%), each leg (18%), anterior torso (18%), posterior torso (18%), and perineum (1%). This method allows rapid, standardized estimation of burn size, which is critical for fluid resuscitation, monitoring for complications, and treatment planning in burn patients.
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