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 A
Explanation
Choice A rationale
The High-Fowler’s position, with the client sitting upright at a 90-degree angle, is ideal for abdominal wound irrigation as it reduces the risk of fluid accumulation in the wound area and promotes drainage.
Choice B rationale
The side-lying position is not typically used for abdominal wound irrigation because it can cause pooling of the irrigation solution and does not facilitate easy access to the wound site.
Choice C rationale
The supine position, with the client lying flat on their back, is not suitable for abdominal wound irrigation as it can lead to fluid retention in the wound and does not aid in drainage.
Choice D rationale
The dorsal recumbent position, with the client lying on their back with knees bent, is also not optimal for abdominal wound irrigation due to the potential for fluid to collect in the wound area.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Adequate fibroblast function is crucial for wound healing as fibroblasts play a key role in the formation of new connective tissue and collagen, which are essential for the repair process.
Choice B rationale
Intrinsic factor is not directly related to wound healing; it is a glycoprotein produced by the stomach lining that is necessary for the absorption of vitamin B12.
Choice C rationale
The synthesis of collagen is vital for wound healing because collagen is the main structural protein in the skin and other connective tissues, providing strength and support to the wound site.
Choice D rationale
While hemoglobin is essential for transporting oxygen in the blood, it is not a factor in the local wound healing process.
Choice E rationale
Adequate phagocytosis is important in wound healing as it involves the ingestion and removal of pathogens and debris by phagocytes, which is a critical step in preventing infection and allowing the healing process to proceed.
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