Nokea
The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?
- A. Serous drainage
- B. Purulent drainage
- C. Sanguineous drainage
- D. Serosanguineous drainage
Correct Answer: C
Rationale: Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.
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The health care provider has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
- A. Weigh the patient to estimate the weight of the saturated dressing.
- B. Reinforce the dressing.
- C. Circle and date the outline of the exudate on the dressing.
- D. Count each dressing as 1 mL of drainage.
Correct Answer: C
Rationale: Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.
The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
- A. Call the RN.
- B. Cover the bowel with a sterile saline dressing.
- C. Turn the patient to the side of the evisceration.
- D. Raise the patient up to a high Fowler's position.
Correct Answer: B
Rationale: Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler's position to relieve strain on the suture line.
The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
- A. 50 mL
- B. 100 mL
- C. 200 mL
- D. 300 mL
Correct Answer: D
Rationale: Drainage greater than 300 mL in 24 hours is considered abnormal.
Which are the phases of wound healing?
- A. Reconstruction
- B. Hemostasis
- C. Inflammation
- D. Granulation
- E. Maturation
Correct Answer: A,B,C,E
Rationale: The steps in wound healing are hemostasis, inflammation, reconstruction, and maturation.
What is the usual length of time before suture removal?
- A. 2 to 3 days
- B. 4 to 5 days
- C. 5 to 6 days
- D. 7 to 10 days
Correct Answer: D
Rationale: Sutures are generally removed within 7 to 10 days.