A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?

Dry brown eschar

Wound tissue firm to palpation

Light yellow exudate

Dark red granulation tissue

Answer and Explanation

The Correct Answer is D

A. Dry brown eschar is a sign of necrotic tissue, which indicates that the wound is not healing properly. Eschar needs to be removed for proper healing to occur.

B. Wound tissue firm to palpation is not a typical sign of healing. Healing tissue tends to be softer, while firm tissue could indicate fibrosis or an abnormal healing process.

C. Light yellow exudate can indicate the presence of infection or the early stages of healing, but it is not as specific a sign of healing as granulation tissue. Granulation tissue is a more definitive sign of healing.

D. Dark red granulation tissue is a sign of healthy healing tissue. It consists of new blood vessels and is an indication that the wound is in the proliferative phase of healing, which is a positive sign.

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Correct Answer is D

Explanation

A. Asking the client if they are afraid of needles may not address the root of the client's fear and could limit the conversation. It may also imply that their fear is based solely on needles, which may not be the case.

B. While the procedure may provide relief, telling the client they will feel better immediately may minimize their concerns and give false assurance. It’s more important to explore the client’s feelings first.

C. While asking the client to explain why they are scared is an open-ended question, it could make the client feel pressured to elaborate on their fears. It’s better to create a supportive environment by asking to discuss concerns more broadly.

D. This response acknowledges the client’s fear and invites them to express their concerns in a nonjudgmental and open way, which helps build trust and allows the nurse to address the client’s specific worries.

A. Limit the client's fluid intake to 2,000 mL daily. B. Massage the client's legs every 4 hr while they are awake. C. Encourage the client to perform circumduction of the feet. D. Keep the client's knees in a flexed position while they are in bed.

Correct Answer is C

Explanation

A. Limiting fluid intake is not appropriate for preventing venous thromboembolism (VTE). Adequate hydration is important to maintain blood volume and prevent clot formation.

B. Massaging the client's legs is not recommended, as it can dislodge a clot if one is present, increasing the risk of embolism.

C. Encouraging circumduction of the feet (circular motion of the feet) helps improve circulation and prevent venous stasis, which is a key factor in the development of venous thromboembolism.

D. Keeping the client's knees in a flexed position can increase the risk of venous stasis and clot formation. The client should be encouraged to keep their legs straight and perform exercises to promote circulation.

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A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?

Nursing Test Bank

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