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A nurse is assessing a client's wound in the stages of healing. Which of the following areas of the wound represents granulation tissue? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[333.4270782470703,393.4270782470703],\"yRanges\":[222.1666259765625,282.1666259765625]}"

Granulation tissue is a key component of the healing process for wounds and appears as new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It typically appears red or pink, indicating the presence of new blood vessels (capillaries). It has a moist, bumpy, or grainy texture. The tissue might look uneven or pebbled. It progressively covers the wound bed, starting from the edges and moving toward the center, eventually filling the wound cavity.

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Correct Answer is D

Explanation

A. Give the client more than one choice for resolving the conflict. While providing choices can be beneficial in some situations, it is not a direct action to ensure immediate environmental safety when a client is escalating aggressively.
B. Move toward the client using an aggressive stance. This approach is inappropriate and can escalate the situation further. A calm and non-threatening demeanor is essential in managing an aggressive client.
C. Choose two staff members to represent the staff and speak to the client. Having multiple staff members engage with an agitated client can sometimes help, but it’s crucial that any interaction is done calmly and without escalating the situation.
D. Stand between the client and the doorway of the room. This is the most appropriate action to ensure safety. Positioning yourself between the client and the exit can prevent the client from leaving the room and potentially harming themselves or others while ensuring a safe space to de-escalate.

A. Place the client in the prone position. B. Insert the lubricated tip 2.5 cm (1 in) into the anal canal. C. Hang the solution bag 7.5 cm (3 in) above the rectum. D. Raise the solution bag if the client exhibits pain during the procedure. E. Encourage the client to retain the enema solution for 10 min.

Correct Answer is ["E"]

Explanation

A. Place the client in the prone position. The client should be placed in the Sims' (left lateral) position for enema administration.
B. Insert the lubricated tip 2.5 cm (1 in) into the anal canal. The lubricated tip should be inserted 7.5-10 cm (3-4 inches) into the anal canal.
C. Hang the solution bag 7.5 cm (3 in) above the rectum. The solution bag should be hung approximately 30 cm (12 inches) above the rectum.
D. Raise the solution bag if the client exhibits pain during the procedure. The solution bag should be lowered or the flow rate slowed if the client experiences pain.
E. Encourage the client to retain the enema solution for 10 min. Retaining the enema solution for a period of time enhances its effectiveness.

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A nurse is assessing a client's wound in the stages of healing. Which of the following areas of the wound represents granulation tissue? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

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Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?

Correct Answer is D

Explanation

A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Correct Answer is ["E"]

Explanation

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