A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

Increase in serosanguineous exudate from a client's wound

Deep red color on the center of a client's wound

Erythema on the skin surrounding a client's wound

Inflammation noted on the tissue edges of a client's wound

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the correct choice because an increase in serosanguineous exudate (a mixture of blood and clear fluid) from a client's wound indicates infection, inflammation, or trauma to the wound. This is a sign of wound deterioration, not healing.

Choice B reason: This is the correct choice because a deep red color on the center of a client's wound indicates granulation tissue, which is new tissue that forms during the healing process. Granulation tissue fills the wound bed and provides a foundation for epithelialization (the growth of new skin over the wound).

Choice C reason: This is not the correct choice because erythema (redness) on the skin surrounding a client's wound indicates irritation, inflammation, or infection of the skin. This is a sign of wound complication, not healing.

Choice D reason: This is not the correct choice because inflammation on the tissue edges of a client's wound indicates infection, trauma, or necrosis (death) of the tissue. This is a sign of wound impairment, not healing.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice because this information is relevant and important for the physical therapist. A hemoglobin of 5 g/dL indicates severe anemia, which can cause fatigue, weakness, shortness of breath, and palpitations. The physical therapist should be aware of the client's condition and adjust the therapy accordingly. The physical therapist should also monitor the client's vital signs, oxygen saturation, and tolerance to activity.

Choice B reason: This is not the correct choice because this information is not relevant or important for the physical therapist. A clean-catch urine test is a diagnostic test that requires the client to collect a midstream urine sample in a sterile container. The physical therapist does not need to know about this test or its results, as it does not affect the client's physical therapy.

Choice C reason: This is not the correct choice because this information is not relevant or important for the physical therapist. Opioid-induced constipation is a side effect of opioid medications that can cause abdominal pain, bloating, and difficulty passing stools. The physical therapist does not need to know about this condition or its treatment, as it does not affect the client's physical therapy.

Choice D reason: This is not the correct choice because this information is not relevant or important for the physical therapist. A new diagnosis of colorectal cancer is a serious and life-changing condition that requires medical and surgical interventions. The physical therapist does not need to know about this diagnosis or its prognosis, as it does not affect the client's physical therapy.

A. A client who has a red tag B. A client who has a green tag C. A client who has a yellow tag D. A client who has a black tag

Correct Answer is A

Explanation

Choice A reason: A client who has a red tag is the first priority for the nurse, as it indicates that the client has life-threatening injuries that require immediate attention and treatment. The nurse should assess and stabilize the client as soon as possible.

Choice B reason: A client who has a green tag is the last priority for the nurse, as it indicates that the client has minor injuries that do not require urgent care. The nurse should assess and treat the client after all other clients have been attended to.

Choice C reason: A client who has a yellow tag is the second priority for the nurse, as it indicates that the client has serious injuries that require timely care but can wait for a short period of time. The nurse should assess and treat the client after the red-tagged clients have been stabilized.

Choice D reason: A client who has a black tag is not a priority for the nurse, as it indicates that the client is deceased or has fatal injuries that are beyond the scope of care. The nurse should not attempt to resuscitate or treat the client, but rather focus on the clients who have a chance of survival.

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A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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