A nurse is caring for a client who has a pressure injury. Which of the following findings indicates the need for a referral to a wound care specialist?
Indication of slough in the wound bed
Minimal signs of induration at the wound edges
Epithelialization noted in areas of tissue loss
Presence of granulated tissue over the wound
The Correct Answer is A
Rationale:
A. Indication of slough in the wound bed signals non-viable tissue that can impede healing and increase the risk of infection. A wound care specialist can provide expertise in advanced wound management, including debridement, specialized dressings, and evidence-based interventions to promote healing.
B. Minimal signs of induration at the wound edges are not necessarily concerning and may reflect normal early healing processes. This finding alone does not warrant a referral.
C. Epithelialization noted in areas of tissue loss indicates that the wound is healing appropriately, as new epithelial tissue is forming. Referral is not needed when healing is progressing normally.
D. Presence of granulated tissue over the wound also indicates healthy healing, as granulation tissue reflects vascularized tissue forming in the wound bed. A specialist referral is unnecessary in this context.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. A client who is ambulatory and receiving IV chemotherapy can evacuate independently or with minimal assistance, so they are not the highest priority during an emergency.
B. A client in Buck’s traction requires assistance for safe movement, but they are generally stable and can be evacuated after higher-risk clients.
C. A client who is postoperative with a chest tube is at risk but is likely stable and can be evacuated with assistance. Evacuation should be careful to maintain tube function, but they are not the immediate priority.
D. A client who is confused and restrained is the highest priority for evacuation. They are at risk for injury, cannot follow instructions, and may struggle to move independently. During a fire or other emergency, protecting clients who cannot protect themselves comes first.
Correct Answer is A
Explanation
Rationale:
A. Clinical indicators are specific, measurable criteria used to evaluate the outcomes of care. They reflect the quality and effectiveness of nursing interventions, such as rates of patient falls, infection rates, or medication errors. Using clinical indicators allows the nurse manager to quantify results and determine if the quality improvement project is achieving its goals.
B. Cause-and-effect diagrams (also called fishbone or Ishikawa diagrams) are tools used to identify potential causes of a problem. While helpful for analyzing contributing factors and planning interventions, they do not measure outcomes.
C. SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool used to convey information clearly among healthcare providers. It is not a tool for measuring outcomes but for improving communication and patient safety.
D. Flowcharts are visual tools that depict the sequence of steps in a process. They help understand workflow or identify process inefficiencies, but they do not directly measure clinical outcomes.
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