A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Sanguineous drainage in the suction device

Granulation tissue on the surface of the wound

Musty odor from the foam dressing upon removal

Peeling of the edges of the transparent dressing

Answer and Explanation

The Correct Answer is B

A. Sanguineous drainage in the suction device:
May occur early on, but persistent sanguineous drainage is not a sign of healing.

B. Granulation tissue on the surface of the wound:
Granulation tissue is pink, healthy tissue that indicates wound healing.

C. Musty odor from the foam dressing upon removal:
Could indicate infection or dressing degradation, not healing.

D. Peeling of the edges of the transparent dressing:
Could compromise the seal of the VAC system and does not reflect wound healing.

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Correct Answer is A

Explanation

A. Swelling and tenderness around the wound:
These are classic signs of infection, indicating inflammation and possible bacterial invasion.

B. Urticaria and itching around the wound:
These are signs of an allergic reaction, not infection.

C. Serosanguineous drainage from the wound:
This is normal wound drainage, especially in early healing.

D. Brown crusting over the wound:
This may indicate scab formation or dried exudate, not necessarily infection.

A. A shallow, ruptured or intact skin blister without slough B. Unbroken skin with un-blancheable erythema C. A deep crater without visible bone, tendon, or muscle D. Full-thickness tissue loss extending to underlying support structures

Correct Answer is C

Explanation

A. A shallow, ruptured or intact skin blister without slough:
Describes a Stage 2 pressure ulcer.

B. Unbroken skin with un-blancheable erythema:
This is a Stage 1 pressure ulcer.

C. A deep crater without visible bone, tendon, or muscle:
Correct. This describes a Stage 3 pressure ulcer with full-thickness tissue loss and subcutaneous damage.

D. Full-thickness tissue loss extending to underlying support structures:
This describes a Stage 4 pressure ulcer.

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A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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