A nurse is caring for a patient in a medical-surgical unit.
The patient’s current diagnoses include type 2 diabetes mellitus and a past medical history of a left below-the-knee amputation 5 years ago.
The nurse is at the patient’s bedside for a dressing change.
The patient’s heart sounds (S1 and S2) are auscultated, with a rate of 76/min. The patient’s respirations are even and regular at 16/min.
The negative pressure wound therapy dressing is removed. Granulation tissue covers the wound bed.
There is slight erythema at the wound edges. The surrounding tissue is warm to touch.
There is no odor present.
The pressure injury is 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point.
There are two tunnels measuring 5 cm (2 in) and 3 cm (1.2 in). The dressing is reapplied and sealed.
The intermittent pressure setting is at 125 mm Hg. The patient reports pain as a 2 on a scale from 0 to 10 and tolerated the procedure well.

Which of the following findings indicate an improvement in the patient’s condition?

Granulation tissue covers the wound bed.

Slight erythema at wound edges.

The surrounding tissue is warm to touch.

The patient reports pain as a 2 on a scale from 0 to 10. .

Answer and Explanation

The Correct Answer is A

Choice A rationale

Granulation tissue covering the wound bed is a positive sign of wound healing. Granulation tissue is a key component of the wound healing process, typically forming during the proliferation phase. It consists of new connective tissue and tiny blood vessels that develop in the wound bed as part of the body’s response to injury. Therefore, the presence of granulation tissue covering the wound bed indicates an improvement in the patient’s condition.

Choice B rationale

Slight erythema at the wound edges could be a sign of inflammation or infection. Erythema, or redness of the skin, is often associated with inflammation or infection. While it can be a normal part of the healing process, persistent or increasing erythema could indicate a problem such as infection or irritation. Therefore, slight erythema at the wound edges does not necessarily indicate an improvement in the patient’s condition.

Choice C rationale

The surrounding tissue being warm to touch could be a sign of inflammation or infection. When skin feels hot to the touch, it often means that the body’s temperature is hotter than normal. This can happen due to an infection or an illness, but it can also be caused by an

environmental situation that increases body temperature. Therefore, the surrounding tissue being warm to touch does not necessarily indicate an improvement in the patient’s condition.

Choice D rationale

The patient reporting pain as a 2 on a scale from 0 to 10 could indicate that the patient’s pain is minor. On a pain scale, a score of 2 usually indicates minor pain. However, pain is a subjective experience and can vary greatly among individuals. Therefore, while a lower pain score generally suggests less severe pain, it does not necessarily indicate an improvement in the patient’s overall condition.

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Correct Answer is A

Explanation

The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.

A. Wear an N95 mask when caring for the patient. B. Place a container for soiled linens inside the patient’s room. C. Wear a sterile, water-resistant gown if within 3 feet of the patient. D. Ensure the patient’s room is well-ventilated.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.

Choice B rationale

Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.

Choice C rationale

Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.

Choice D rationale

Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?

Correct Answer is A

Explanation

A nurse is placing a patient on isolation precautions. The patient’s diagnostic results at 1400 are given.Which of the following actions should the nurse take?

Correct Answer is ["A","B"]

Explanation

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