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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?

A.

Serous

B.

Purulent

C.

Serosanguineous

D.

Sanguineous

Answer and Explanation

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 C

Explanation

Rationale:

A. Placing the client supine with knees bent helps reduce abdominal pressure, but it is not the first action. Protecting the exposed organs from infection or drying out takes priority.

B. Assessing for manifestations of shock is important, but the immediate concern is to prevent further injury or infection to the exposed tissues.

C. The priority action when a wound eviscerates is to cover the area with a sterile dressing moistened with 0.9% sodium chloride solution to keep the organs moist and prevent infection until surgical repair can be done.

D. Raising the head of the bed slightly may help reduce pressure, but it is not the most immediate action compared to covering the exposed organs to prevent drying or infection.

Correct Answer is A

Explanation

Rationale:

A. Cleansing the wound with 0.9% sodium chloride saline irrigation helps remove debris and bacteria from the wound surface, ensuring that the specimen collected for culture reflects the infection present in the wound rather than contaminants.

B. Including intact skin at the wound edges in the culture is not advisable, as it may introduce flora that do not represent the infection. The focus should be on obtaining a specimen from the wound itself.

C. Swabbing an area of skin away from the wound to identify normal flora is not relevant when assessing an infection. The culture should target the actual infected area to determine the causative organisms.

D. Irrigating the wound with an antiseptic prior to obtaining the specimen can alter the bacterial load present and lead to inaccurate culture results, as it may kill or wash away organisms that need to be identified.

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