A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Muscular strength assessment
Sensation assessment
Sleep assessment
Pulse oximetry assessment
The Correct Answer is D
A. Muscular strength assessment: While muscular strength is important for overall mobility and health, it is not a key factor in wound healing. Wound healing is primarily influenced by oxygenation, perfusion, and nutrition.
B. Sensation assessment: While sensation is important in patients with conditions like diabetes (due to the risk of neuropathy and unnoticed wounds), it is not the most relevant assessment for determining wound healing.
C. Sleep assessment: Adequate rest is beneficial for healing, but sleep assessment is not the primary factor that determines wound healing. Other physiological factors play a greater role.
D. Pulse oximetry assessment: Oxygenation is a critical factor in wound healing. Low oxygen levels impair tissue repair, increase infection risk, and slow cell regeneration. Pulse oximetry assesses the oxygen levels in the blood, making it the most relevant assessment for wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.
B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.
C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.
D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.
Correct Answer is C
Explanation
A. Assess the pedal pulses for a full minute. Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate.
B. Assess the apical pulse with a Doppler device. A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation.
C. Assess the apical pulse for a full minute. When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias.
D. Assess the pedal pulses with a Doppler device. Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.
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