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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Performing a cognitive assessment is part of the nurse’s routine assessment responsibilities. While important for care planning, it is not an example of advocacy because it does not directly support the client’s rights or access to services.
B. Reorienting the client is an intervention to support safety and reduce confusion, but it is a direct care activity rather than advocacy.
C. Requesting a referral for reminiscent therapy sessions is an example of client advocacy. The nurse is acting on the client’s behalf to access services that enhance quality of life, promote cognitive stimulation, and support emotional well-being. Advocacy involves ensuring the client’s needs and preferences are addressed within the healthcare system, especially when they may not be able to request these services independently.
D. Providing assistance with ambulation is a safety intervention and part of basic nursing care. While it supports the client, it does not represent advocacy, which focuses on supporting the client’s rights, choices, and access to resources.
Correct Answer is C
Explanation
Rationale:
A. Documentation in the incident report should be objective and factual, but the phrase “Entered room and discovered client lying prone on the floor” is somewhat narrative and includes unnecessary detail about the nurse’s actions rather than the client’s condition.
B. Including statements about the incident report in the nurse’s notes is inappropriate. Incident reports are separate legal documents and should not be referenced in the medical record to avoid legal implications.
C. Documenting in the incident report that the client was found lying on the floor after falling out of bed is objective, factual, and concise, which is appropriate for incident reporting. It clearly communicates the event without including speculation, blame, or unnecessary detail.
D. Writing “Incident report completed and filed” in the nurse’s notes is not appropriate. The nurse’s notes should focus on the client’s condition, assessment findings, and care provided, not the completion of the incident report.
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