Which statement provides the best documentation of the amount of wound drainage?
Two 4x4 gauze cloths saturated with purulent drainage.
Large amounts of exudate removed with dressing.
Dressing dry on top, wet adjacent to the wound.
Outer dressing dry and intact, moderate drainage noted underneath.
The Correct Answer is A
Two 4x4 gauze cloths saturated with purulent drainage. This statement provides the best documentation of the amount of wound drainage because it specifies the size and number of gauze cloths, the type and amount of exudate, and the presence of infection
Choice B is wrong because it does not indicate the size or number of dressings, the type or amount of exudate, or the presence of infection.
Choice C is wrong because it does not indicate the size or number of dressings, the type of exudate, or the presence of infection.
Choice D is wrong because it does not indicate the size or number of dressings, the type of exudate, or the presence of infection.
Normal ranges for wound drainage are categorized as scant, minimal, moderate, or large/copious The type of wound drainage can be described as serous, sanguineous, serosanguineous, or purulent
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.
The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.
Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.
Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.
The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.
Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.
The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.
Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.
The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.
Correct Answer is ["A","C","D"]
Explanation
These are natural respiratory defense mechanisms that help defend against infection.
Choice A is correct because cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.
This prevents pathogens and particles from reaching the lungs.
Choice B is wrong because the respiratory tract does not cool and dry the air being inhaled. In fact, the respiratory tract warms and humidifies the air to facilitate gas exchange.
Choice C is correct because cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.
Lysozymes are enzymes that break down the cell walls of bacteria.
Choice D is correct because macrophages engulf and destroy bacteria found in the alveoli. Macrophages are a type of white blood cell that act as scavengers of foreign invaders.
Choice E is wrong because high concentrations of oxygen and carbon dioxide do not aid the defense mechanisms.
On the contrary, high levels of these gases can impair gas exchange and cause acid-base imbalance.
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