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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Rationale:
A. A guaiac test does not check for parasites. Tests for parasites typically involve microscopic examination of the stool or other specialized tests.
B. Steatorrhea refers to fat in the stool, and this is detected through tests that measure fat content in the stool, not a guaiac test.
C. A guaiac test is specifically used to detect occult (hidden) blood in the stool, which can indicate gastrointestinal bleeding, polyps, or colorectal cancer.
D. Bacteria in the stool is detected through stool cultures, not a guaiac test.
Correct Answer is D
Explanation
Rationale:
A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.
B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.
C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.
D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.