When changing the dressing on the patient’s right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?
Sanguineous
Serous
Serosanguineous
Purulent
The Correct Answer is C
Choice A rationale
Sanguineous drainage is indicative of active bleeding and is typically bright red due to the presence of red blood cells. This type of drainage is not yellow-red and is not consistent with the description provided.
Choice B rationale
Serous drainage is clear and watery, and it is the fluid that is seen in blisters. It does not have a yellow-red color, so it does not match the description of the drainage observed.
Choice C rationale
Serosanguineous drainage is a mixture of serous and sanguineous drainage. It is typically light red or pink in color, which corresponds with the moist yellow-red stain described, indicating the presence of both plasma and red blood cells.
Choice D rationale
Purulent drainage is thick and opaque, usually yellow, green, or brown, and is associated with infection. The description of a yellow-red stain does not suggest that the drainage is purulent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A:
es and moisture to digest necrotic tissue. While Dakin's solution can support this process by maintaining a moist wound environment, it does not directly cause autolytic debridement.
Choice B:
Sharp debridement involves the use of a scalpel, scissors, or other sharp instrument to remove dead tissue. Dakin's solution does not perform this function.
Choice C:
Enzymatic debridement involves the use of a topical application of enzymes to break down necrotic tissue. Dakin's solution does not contain these enzymes.
Choice D:
This is the correct choice. Dakin's solution, a sodium hypochlorite-based solution, is used for chemical debridement¹. It can be used to irrigate the wound bed or as the solution for wet-to-moist dressing, effectively cleansing away wound debris and helping create the ideal environment for healing.
Correct Answer is C
Explanation
Choice A rationale
Excessive gas is not typically an indication of wound dehiscence. While it may cause discomfort, it does not suggest that the wound layers have separated.
Choice B rationale
A complaint of constipation is a common postoperative concern due to decreased mobility and use of narcotics but is not a sign of wound dehiscence.
Choice C rationale
Increased drainage from the wound, especially if the fluid is clear or serous, can be an early sign of dehiscence, indicating that the wound layers are separating and fluid is accumulating.
Choice D rationale
Increased pallor of the surgical site might indicate poor perfusion but is not a direct sign of dehiscence. Dehiscence would more likely show signs of inflammation or unusual discharge.
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