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?
Wound tissue firm to palpation
Dry brown eschar
Light yellow exudate
Dark red granulation tissue
The Correct Answer is D
A pressure ulcer is a localized injury to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture.
Granulation tissue is new connective tissue and blood vessels that form on the surface of a wound during healing . It is usually dark red or pink in color and moist in appearance . Wound tissue that is firm to palpation may indicate edema, inflammation, or infection . Dry brown eschar is dead tissue that covers the wound and prevents healing . Light yellow exudate is a sign of wound infection or necrosis .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is a low hemoglobin level, which may indicate blood loss. The nurse should report this finding to the provider immediately, as it may require further investigation and intervention, such as blood transfusion.
Correct Answer is D
Explanation
A low potassium level (hypokalemia) can increase the risk for digoxin toxicity because it enhances the binding of digoxin to cardiac cells and increases its effects on cardiac contractility and electrical conduction. The nurse should monitor the client's potassium level and administer potassium supplements as prescribed if needed. The other electrolytes are not directly related to digoxin toxicity.
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