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 A
Explanation
Formed stool two times per day, every day, for one week. This indicates that bowel training is attaining the desired outcome because it shows regularity and consistency of bowel movements without the use of laxatives or enemas.
Choice B is wrong because soap sud enemas are not recommended for bowel training as they can irritate the bowel and cause fluid and electrolyte imbalance.
Choice C is wrong because continued use of laxatives can inhibit the natural defecation reflexes and cause dependency.
Choice D is wrong because a formed, soft stool at regular intervals without the use of a laxative is a normal defecation pattern, not an indication of fecal incontinence.
Correct Answer is A
Explanation
An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.
B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.
C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.
D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.
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