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?
Minimal signs of induration at the wound edges
Epithelialization noted in areas of tissue loss
Presence of granulated tissue over the wound
Indication of slough in the wound bed
The Correct Answer is D
A. Minimal induration (hardening) at wound edges can be a normal inflammatory response and may not require specialist referral.
B. Epithelialization indicates healing and is a positive sign.
C. Granulation tissue presence suggests the wound is progressing through the healing stages.
D. Slough in the wound bed indicates necrotic tissue, which can impede healing and often requires specialized wound care management. This finding warrants referral to a wound care specialist.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Respecting and documenting a client’s right to refuse treatment supports their autonomy, a core principle of advocacy.
B. Offering clear, understandable information empowers the client to make informed decisions about their care—an essential part of advocacy.
C. Performing procedures without explanation or consent (even on clients with cognitive impairment) violates advocacy and autonomy. The nurse should attempt to communicate and explain procedures as clearly as possible.
D. Ensuring effective communication through appropriate resources supports the client’s right to understand their care and make informed choices.
E.Client advocacy involves basing care on the client’sgoals and preferences—not solely the nurse’s objectives.
Correct Answer is ["B","C"]
Explanation
A. Petroleum jelly is not recommended for tracheostomy care because it can be aspirated and cause airway obstruction.
B. An obturator is essential to have on hand in case the tracheostomy tube becomes dislodged. It allows for safe reinsertion of the tube and is a critical emergency supply.
C. An oxygen tank may be necessary if the client requires supplemental oxygen therapy at home, depending on their respiratory status.
D. Cotton balls are not recommended for tracheostomy care because fibers can be aspirated and cause airway obstruction.
E. Pipe cleaners are unsafe for tracheostomy care because they can break or leave fragments in the airway. Proper tracheostomy cleaning supplies include sterile swabs or suction catheters.
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