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 C
Explanation
Prealbumin is a protein that is produced by the liver and is used as a marker of nutritional status.
It has a short half-life, so changes in pre albumin levels can reflect recent changes in nutritional status.
Monitoring pre albumin levels can help assess the effectiveness of total parenteral nutrition.
Lipase is an enzyme that is produced by the pancreas and is not used to monitor overall nutritional status.
B) C-reactive protein is a marker of inflammation and is not used to monitor overall nutritional status.
D) Creatinine is a waste product that is produced by muscle metabolism and is not used to monitor overall nutritional status.
Correct Answer is B
Explanation
“Monitor urinary output for retention.” Urinary retention is a common side effect of opioid use and should be monitored.
Choice A is not correct because itching can be a side effect of opioids and does not necessarily indicate an allergic reaction.
Choice C is not correct because restricting fluid intake can worsen constipation.
Choice D is not correct because antiemetics may be prescribed to manage nausea and vomiting, which are common side effects of opioids.
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