A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?
Infection
Granulation tissue
An inflammatory response
Decreased perfusion
The Correct Answer is B
A. Infection: Infected wounds may have purulent drainage, foul odor, warmth, or increased pain, but red, soft tissue that bleeds easily typically indicates healing, not infection.
B. Granulation tissue: Granulation tissue is healthy new tissue that appears red, moist, and bleeds easily. It is a sign of wound healing.
C. An inflammatory response: Inflammation typically shows redness, warmth, swelling, and pain—not soft red tissue that bleeds easily.
D. Decreased perfusion: Decreased perfusion would lead to pale or necrotic tissue, not red bleeding tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. "Monitor your blood pressure on a regular basis." Lisinopril is an ACE inhibitor used to treat hypertension. Clients should monitor BP regularly to assess effectiveness and prevent hypotension.
B. "Your cholesterol levels should be monitored monthly while taking this medication." Cholesterol monitoring is not routinely required for lisinopril; it is more relevant for statins.
C. "Notify your doctor immediately if you become pregnant." Lisinopril is contraindicated in pregnancy due to its risk of fetal injury or death.
D. "Report the development of a persistent dry cough." A dry cough is a well-known side effect of ACE inhibitors and should be reported to the provider.
E. "Make sure your diet contains a lot of potassium-rich foods." Lisinopril can cause hyperkalemia, so clients should avoid excessive potassium intake.
Correct Answer is D
Explanation
A. Blood pressure 160/94 mm Hg: This blood pressure is elevated and an indication for metoprolol, a beta-blocker that helps lower blood pressure.
B. Respiratory rate 18/min: This is within normal range (12–20 breaths/min) and is not a contraindication for metoprolol.
C. Oxygen saturation 95%: This is within normal limits and not a reason to withhold the medication.
D. Heart rate 50/min: Metoprolol can lower heart rate. A heart rate <60 bpm is a contraindication because it increases the risk of bradycardia. The nurse should withhold and notify the provider.
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