A nurse assessing a client's wound documents the finding of ...

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A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?
 
  A) Clear, watery blood
  B) Large numbers of red blood cells
  C) Mixture of serum and red blood cells
  D) White blood cells, debris, bacteria

Question 2

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected?
 
  A) Full-thickness skin loss
  B) Skin pallor
  C) Blister formation
  D) Eschar formation

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Answer to Question 1

Ans: D
Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to
blood tinged.

Answer to Question 2

Ans: A
A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss.

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