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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
Order: Mycostatin 600,000 units PO every 8 hr
Available: Mycostatin 100,000 units/Ml
ml to administer =600,000 units /100,000 units/ml
= 6ml
Correct Answer is A
Explanation
A. It divides the body into eight equal regions, with each region representing 12.5% of the total body surface area:
The Rule of Nines assigns percentages to major body parts (e.g., each leg = 18%, each arm = 9%, anterior torso = 18%) totaling 100%.
B. It divides the body into twelve equal regions, with each region representing 59% of the total body surface area:
Incorrect math and region count; total exceeds 100% and is not part of the rule of nines.
C. It divides the body into six equal regions, with each region representing 15% of the total body surface area:
Also incorrect; not consistent with the actual anatomic distribution used in the rule of nines.
D. It divides the body into nine equal regions, with each region representing 100% of the total body surface area:
Nonsensical; if each is 100%, total would be 900%, which is not accurate.
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