A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?
Serous
Purulent
Serosanguineous
Sanguineous
The Correct Answer is A
Rationale:
A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.
B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.
C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.
D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.
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Correct Answer is D
Explanation
Rationale:
A. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.
B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.
C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.
D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.
Correct Answer is B
Explanation
Rationale:
A. Applying cornstarch can absorb moisture; however, it may not be the most effective method to maintain skin integrity and can cause friction when applying.
B. A diet high in protein is essential for skin health and repair, as it supports tissue regeneration and helps prevent skin breakdown in vulnerable clients.
C. Massaging bony prominences is not recommended, as it may cause further tissue damage or disrupt circulation. Instead, padding and reducing pressure on these areas is more beneficial.
D. Repositioning the client every 3 hours may not be frequent enough for someone at high risk for skin breakdown; generally, repositioning should occur at least every 2 hours to alleviate pressure.