A nurse is assessing a client who has a pressure ulcer.
Which of the following findings should the nurse expect as an indication the wound is healing?
Dark red granulation tissue.
Light yellow exudate.
Dry brown eschar.
Wound tissue firm to palpation.
The Correct Answer is A
Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process.
The presence of dark red granulation tissue is a sign that the wound is healing.
B. Light yellow exudate: Light yellow exudate may indicate the presence of infection and is not a sign of healing.
C. Dry brown eschar: Dry brown eschar is dead tissue that needs to be removed for the wound to heal properly.
D. Wound tissue firm to palpation: Wound tissue firm to palpation is not a specific sign of healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“Furosemide.” The nurse should anticipate administering furosemide because the client’s symptoms of bounding peripheral pulses, hypertension, and distended jugular veins may indicate fluid overload.
Furosemide is a diuretic medication that can help reduce fluid overload by increasing urine output.
Choice A is incorrect because diphenhydramine is an antihistamine medication that is not used to treat fluid overload.
Choice C is incorrect because acetaminophen is a pain reliever and fever reducer that is not used to treat fluid overload.
Choice D is incorrect because pantoprazole is a proton pump inhibitor that is used to treat acid reflux and stomach ulcers, not fluid overload.
Correct Answer is D
Explanation
The client’s ABG results show a pH of 7.24, which is below the normal range of 7.35-7.45 and indicates acidosis.
The PaCO2 is within the normal range of 35-45 mm Hg, indicating that the acidosis is not caused by a respiratory issue.
The HCO3 level is 18 mEq/L, which is below the normal range of 22-28 mEq/L and indicates a primary metabolic cause for acidosis.
Respiratory acidosis is not indicated by the ABG results as the PaCO2 is within the normal range.
B) Metabolic alkalosis is not indicated by the ABG results as the pH and HCO3 levels are below their respective normal ranges.
C) Respiratory alkalosis is not indicated by the ABG results as the pH is below the normal range and the PaCO2 is within the normal range.
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