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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Raising the head of the bed to a 90° angle is not recommended for clients with hemiplegia as it can cause discomfort and increase the risk of pressure ulcers. A semi-Fowler's position (30° to 45°) is usually more appropriate.
B. While using moisturizing lotion on bony prominences is important to prevent skin breakdown, it is not specific to the management of hemiplegia. The focus for hemiplegia is more on positioning, mobility, and preventing complications like contractures.
C. Placing pillows between the client's knees when in a side-lying position is an appropriate intervention for a client with hemiplegia. This helps maintain proper alignment of the limbs, prevents pressure sores, and reduces the risk of contractures in the affected side.
D. Instructing the client to sit on a rubber ring is generally not recommended for clients with hemiplegia, as it may not provide adequate support and can lead to improper posture or skin breakdown. Proper seating supports and positioning should be emphasized instead.
Correct Answer is B
Explanation
A. A 25-gauge saline lock is too small for administering fresh frozen plasma. Plasma should be transfused through a larger gauge catheter (typically 18 or 20 gauge) to ensure proper flow and minimize complications.
B. Fresh frozen plasma should be administered as soon as possible after thawing, typically within 30 minutes to 1 hour, to maintain its efficacy and avoid bacterial growth.
C. Fresh frozen plasma should not be transfused over 4 hours. It is usually given within 1 to 2 hours to minimize the risk of bacterial contamination and ensure proper clotting factor effectiveness.
D. Holding the transfusion if the client is actively bleeding is not appropriate. In fact, fresh frozen plasma is often administered to clients who are actively bleeding or who have clotting disorders to replace deficient clotting factors.
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