While changing a client's dressing, the nurse notes thick ...

[Anajune7]

While changing a client's dressing, the nurse notes thick yellowgreen drainage on the gauze. How should the nurse document this wound's drainage?
 
  1. Purulent.
  2. Serous.
  3. Sanguineous.
  4. Serosanguinous.

Question 2

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client?
 
  1. Poor skin turgor.
  2. Elevated body temperature.
  3. Diminished pain sensation.
  4. Thin epidermis.
  5. Dry skin.

[ntsoane kedibone]

Answer to Question 1

Correct Answer: 1
Rationale 1: Purulent exudate is thick, and can vary in color, including green and yellow.
Rationale 2: Serous drainage appears watery.
Rationale 3: Sanguineous drainage is red because of the high number of red blood cells.
Rationale 4: Serosanguinous drainage is watery with red blood cells.

Answer to Question 2

Correct Answer: 1,3,4,5
Rationale 1: The older person is more prone to impaired skin integrity because of decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis.
Rationale 2: Elevated body temperature does impact a person's skin integrity, but this could occur at any age, and not just in an older client.
Rationale 3: The older person is more prone to impaired skin integrity because of diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch.
Rationale 4: The older person is more prone to impaired skin integrity because of generalized thinning of the epidermis.
Rationale 5: The older person is more prone to impaired skin integrity because of increased dryness due to a decrease in the amount of oil produced by sebaceous glands.

[Anajune7]

Thanks for the timely response, appreciate it

[juliaf]

Wow, this really help