Nokea
You observe pink drainage from a patient's wound. You would describe this as:
- A. sanguineous
- B. serous
- C. purulent
- D. seropurulent
- E. serosanguineous
Correct Answer: E
Rationale: Serosanguineous drainage is pink, combining clear serous fluid and small amounts of blood.
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A patient's J-P drain should be emptied:
- A. every 2 hours
- B. every 8 hours
- C. when one-half to two-thirds full
- D. only when it needs to be reactivated
- E. when the container is full
Correct Answer: C
Rationale: A J-P drain should be emptied when one-half to two-thirds full to maintain proper suction and prevent complications.
Which one of the following assessment findings makes it impossible to stage a pressure injury?
- A. Purulent drainage
- B. Eschar
- C. Sloughing tissue
- D. Erythema
- E. Drainage
- F. Signs of infection
- G. Undermining
Correct Answer: B
Rationale: Eschar obscures the wound bed, making it impossible to assess the depth and stage of a pressure injury.
Which one of the following interventions would you rateas the most important for care of his pressure injury?
- A. Change the wet-to-damp dressing on his right hipwound gid using sterile technique.
- B. Tell dietary service about his food likes and dislikes.
- C. Reposition the patient every 2 hours around the clock,avoiding the right lateral position.
- D. Assess the condition of the pressure injury once daily.
- E. Provide Foley care every shift.
- F. Work to increase the length of time the patient can tolerate sitting in a chair.
Correct Answer: C
Rationale: Frequent repositioning is the most critical intervention in preventing further skin breakdown and promoting healing of pressure injuries. Since the wound is on his right hip, avoiding the right lateral position helps reduce pressure on the affected area, improving circulation and tissue recovery. This intervention directly addresses pressure relief, which is the primary cause of pressure injuries.
You are caring for a 67-year-old male who had a cerebrovascular accident 3 weeks ago. In addition, he has developed a pressure injury on his right hip. Which of the following data that you collected will be useful in developing a care plan that will address his pressure ulcer?
- A. Last week he weighed 165.5 pounds, and today he weighs 161.8 pounds.
- B. The pressure injury is a stage 3.
- C. He has 250 mL of clear yellow urine in his Foley catheter.
- D. He is not able to sit up in a chair for longer than 15 minutes at a time.
- E. He dislikes cheese, beans, chicken, and fish, but loves steak, eggs, all kinds of nuts, and peanut butter.
- F. His affect is flat.
- G. He has been on an eggcrate mattress while in the hospital.
Correct Answer: A,B,D,E
Rationale: When developing a care plan for a 67-year-old male with a pressure injury, several pieces of collected data are particularly useful. His weight loss from 165.5 to 161.8 pounds over the past week suggests nutritional deficits, which can impair wound healing and should be addressed through dietary interventions. The identification of the pressure injury as stage 3 indicates full-thickness tissue damage and guides the level of wound care required, such as debridement and specialized dressings. His inability to sit in a chair for more than 15 minutes highlights limited mobility, a major risk factor for pressure ulcers, requiring repositioning schedules and pressure-relieving devices. Additionally, while he dislikes some high-protein foods like cheese, beans, chicken, and fish, his preference for steak, eggs, nuts, and peanut butter still offers adequate protein options, which are critical for tissue repair and wound healing. These preferences should be incorporated into his care plan to ensure compliance with nutritional recommendations.
A patient has signs of infection in his left shoulder incision-erythema, warmth, and a small amount of purulent drainage. You prepare to report this to the health-care provider. Which information will you have ready when you call?
- A. Vital signs
- B. Name and dosage of pain medication currently ordered
- C. Appropriate laboratory results
- D. Patient's rating of incisional pain
- E. Description of the wound and drainage
- F. Names of all staff who have changed his dressing since surgery
- G. Signs of infection you observe
Correct Answer: A,C,E,G
Rationale: Vital signs, lab results, wound description, and infection signs are critical for the provider to assess and plan treatment.