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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is an incorrect action by the unit nurse. Alcohol-based hand sanitizer is not effective against Clostridium difficile spores, which can cause severe diarrhea and colitis. The nurse should wash their hands with soap and water after removing gloves to prevent the spread of the infection.
Choice B reason: This is a correct action by the unit nurse. Wearing goggles when emptying the bedpan of liquid stool is a standard precaution that protects the nurse's eyes from exposure to body fluids. The nurse should also wear gloves and a gown when handling the bedpan.
Choice C reason: This is a correct action by the unit nurse. Placing the client in contact precautions is an appropriate measure for clients who have Clostridium difficile. Contact precautions prevent direct or indirect transmission of the infection through contact with the client or the client's environment. The nurse should use a single room or cohort the client with another client who has the same infection.
Choice D reason: This is a correct action by the unit nurse. Cleaning contaminated equipment with bleach-based solution is an effective way to kill Clostridium difficile spores, which can survive on surfaces for a long time. The nurse should follow the manufacturer's instructions for the dilution and contact time of the bleach solution.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the least urgent and most stable condition. A deep-vein thrombosis is a blood clot that forms in a vein, usually in the leg. An INR of 2.0 indicates that the client's blood is within the therapeutic range for anticoagulation therapy, which prevents the clot from growing or breaking off. The nurse should ensure that the client has a prescription for oral anticoagulants, compression stockings, and follow-up appointments before discharging them.
Choice B reason: This is not the correct choice because this client has a serious and potentially life-threatening condition. Tumor lysis syndrome is a complication of chemotherapy that occurs when cancer cells break down rapidly and release their contents into the bloodstream. This can cause electrolyte imbalances, kidney damage, and cardiac arrhythmias. The nurse should monitor the client's vital signs, laboratory values, urine output, and fluid balance, and administer medications and interventions as prescribed.
Choice C reason: This is not the correct choice because this client has a new and acute condition. A new onset of left-sided weakness could indicate a stroke, which is a medical emergency that requires immediate diagnosis and treatment. The nurse should perform a neurological assessment, check the client's blood pressure and blood glucose levels, and activate the stroke protocol.
Choice D reason: This is not the correct choice because this client has a severe and unstable condition. Angina is chest pain that occurs when the heart muscle does not get enough oxygen-rich blood. A troponin level of 3 ng/mL indicates that the client has a high level of cardiac enzymes in the blood, which suggests a heart attack or myocardial infarction. The nurse should administer oxygen, nitroglycerin, aspirin, and morphine as prescribed, and prepare the client for further diagnostic tests and interventions.
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