When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

Purulent.

Serous.

Sanguinous.

Serosanguineous.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.

Choice B rationale:

Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.

Choice C rationale:

Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.

Choice D rationale:

Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.

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Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

A. Ask someone to quickly get an abdominal binder. B. Assist the patient in a supine position. C. Seat the patient in a nearby chair. D. Instruct the patient to pant to reduce abdominal tension.

Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

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When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

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Naxlex Comprehensive Predictor Exams

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

Correct Answer is C

Explanation

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

Correct Answer is B

Explanation

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