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 B

Explanation

A. Decreased metabolic rate:
Burns cause an increase, not decrease, in metabolic rate due to the hypermetabolic state post-injury.

B. Increased capillary permeability:
This is a hallmark of burn injuries. Damaged capillaries leak fluid into interstitial spaces, leading to fluid and electrolyte imbalance.

C. Normal electrolyte levels:
Electrolyte levels are often abnormal in burn patients due to fluid shifts and tissue damage.

D. Excessive fluid intake:
Overhydration can be harmful, but it is not a typical cause of the initial fluid imbalance seen in burns.

A. Reports of joint discomfort B. Elevated temperature C. Denial of pruritus D. Reports of exposure to a skin irritant

Correct Answer is D

Explanation

A. Reports of joint discomfort:
Not typically associated with contact dermatitis.

B. Elevated temperature:
Systemic symptoms like fever are not common in localized contact dermatitis.

C. Denial of pruritus:
Itching (pruritus) is a hallmark symptom of contact dermatitis.

D. Reports of exposure to a skin irritant:
Contact dermatitis occurs following direct contact with an irritant or allergen.

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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

The nurse is taking care of a burn patient with deep partial-thickness burns. Which of the following factors can contribute to fluid imbalance in burn patients?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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