What is the most appropriate nursing intervention for a wound draining bright red sanguineous fluid?
Cover the wound with a dry sterile dressing.
Document the drainage and continue routine wound care.
Apply a warm compress to the wound site.
Apply a cold compress to the wound site.
The Correct Answer is A
A. Cover the wound with a dry sterile dressing: This is the most appropriate action among the choices, assuming the bleeding is minor and the wound needs dressing. A dry sterile dressing protects the wound from contamination and provides a surface for clot formation, which is essential to stop minor capillary bleeding. If the drainage is significant (potential hemorrhage), the best action would be to apply pressure over the dressing and notify the provider, but simply covering it with a sterile dressing is a necessary initial step in wound management.
B. Document the drainage and continue routine wound care: While documentation is necessary, bright red blood is a deviation from normal for most healing wounds and requires intervention beyond routine care, such as assessing vital signs and applying pressure, to ensure it stops.
C. Apply a warm compress to the wound site: A warm compress causes vasodilation, which would increase blood flow and worsen active bleeding.
D. Apply a cold compress to the wound site: While cold causes vasoconstriction which could reduce bleeding, it can also impair the circulation to the wound, potentially causing tissue damage. Direct pressure is the preferred method to stop bleeding.
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Related Questions
Correct Answer is B
Explanation
A. Check the patient's blood sugar levels: This is an important step in assessing a diabetic patient whose high blood sugar can impair healing, but it is not the most immediate priority for an actively infected wound.
B. Assess for signs of systemic infection: A foul odor (purulent drainage) indicates a localized infection. The priority is to assess if that infection is spreading systemically (sepsis) by checking for signs like fever, tachycardia, hypotension, and altered mental status. This assessment dictates the urgency of treatment (e.g., blood cultures, IV antibiotics).
C. Measure the wound dimensions: This is a routine, necessary step for wound documentation but is secondary to assessing the patient's immediate physiological status and the risk of life-threatening sepsis.
D. Apply a new dressing over the wound: This is an expected intervention but is secondary to a thorough assessment for systemic involvement, which guides immediate medical interventions.
Correct Answer is B
Explanation
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.
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