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 B
Explanation
Rationale:
A. Changing the catheter once each shift is unnecessary and can increase the risk of infection. Catheters should be replaced only when clinically indicated.
B. Checking the catheter tubing for kinks or twisting is essential to ensure proper drainage and reduce the risk of infection. This action promotes unobstructed urine flow, which is critical for infection prevention.
C. Replacing the catheter every 3 days is not a standard practice; catheters should be changed based on clinical need rather than a set schedule. This could unnecessarily increase the risk of infection.
D. While cleaning the perineal area is important, using an antiseptic solution daily may cause irritation and disrupt the normal flora of the area. Routine cleaning with mild soap and water is typically recommended instead.
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.