Nokea
The drainage in a patient's Jackson-Pratt drain is red and appears bloody. This drainage is described as
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: B
Rationale: Sanguineous drainage is characterized by red, bloody fluid, typically seen in fresh wounds or surgical drains like a Jackson-Pratt drain.
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Which of these patients is most at risk for developing a pressure injury?
- A. A well-nourished 54-year-old patient who had a left total knee replacement and is up in the chair twice per day
- B. A 78-year-old with a feeding tube who is nonambulatory and is incontinent of bowels and bladder
- C. A 66-year-old who had a myocardial infarction (heart attack) yesterday and is not eating well because of nausea
- D. A 42-year-old with pneumonia who is receiving IV antibiotics and can only get up to go to the bathroom
Correct Answer: B
Rationale: The 78-year-old patient has multiple risk factors: immobility, incontinence, and likely poor skin integrity, increasing pressure injury risk.
Which are accurate statements about a deep tissue pressure injury?
- A. It may be caused by a medical device, such as a splint.
- B. It is deep red, maroon or purple colored, and does not blanch.
- C. It may be intact or nonintact skin.
- D. It is at least 2 cm deep or deeper.
- E. It is the result of prolonged pressure and/or shear force.
Correct Answer: A,B,C,E
Rationale: Deep tissue pressure injuries involve non-blanching discoloration, can be intact or nonintact, and result from pressure/shear, often from devices.
A patient is at risk for wound dehiscence as a result of nutritional issues and medical history. Which interventions should be included in the care plan?
- A. Assist the patient to splint the incision with a pillow when coughing.
- B. Enforce strict bedrest with bathroom privileges only.
- C. Administer stool softeners and antinausea medicine promptly.
- D. Obtain VS every 15 minutes.
Correct Answer: A,C
Rationale: Splinting the incision and preventing straining (via stool softeners/antinausea meds) reduce stress on the wound, preventing dehiscence.
All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.
Which of the following orders would you expect the health-care provider to write after receiving laboratory results for the patient in Question 20?
- A. Bedrest with bathroom privileges
- B. Discharge tomorrow morning
- C. Wound culture and sensitivity
- D. Low-protein diet
Correct Answer: C
Rationale: A wound culture and sensitivity test is appropriate to identify the specific bacteria and effective antibiotics for an infected wound.