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 A
Explanation
A. Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air).
B. Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms.
C. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles.
D. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.
Correct Answer is D
Explanation
A. Hypertension: Diphenhydramine (Benadryl) is an antihistamine that typically causes hypotension, not hypertension. It can have a mild vasodilatory effect, leading to a drop in blood pressure in some patients.
B. Constipation: While some antihistamines can cause mild gastrointestinal effects, constipation is not a primary adverse effect of diphenhydramine. Dry mouth and urinary retention are more common due to its anticholinergic properties.
C. Bradycardia: Diphenhydramine can sometimes cause tachycardia (increased heart rate), especially in elderly patients or those prone to cardiovascular effects. Bradycardia (slow heart rate) is not a usual adverse effect.
D. Sedation: Diphenhydramine is a first-generation antihistamine that crosses the blood-brain barrier and has a sedative effect by blocking histamine receptors in the central nervous system. It is commonly used as a sleep aid for this reason.
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