A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?

Translucent, red tissue

Soft, yellow tissue

Stringy, white tissue

Thick, black tissue

Answer and Explanation

The Correct Answer is A

A. Translucent, red tissue Granulation tissue is red or pink due to increased blood supply and is a sign of healing.
B. Soft, yellow tissue This describes slough, which consists of dead tissue and debris that may delay wound healing.
C. Stringy, white tissue This could indicate fibrin or slough, which may require debridement.
D. Thick, black tissue This describes eschar, which is necrotic (dead) tissue and needs removal for proper wound healing.

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Correct Answer is D

Explanation

A. Enlarged adenoids Enlarged adenoids may contribute to airway obstruction, especially in children, but they are not a complication of OSA.
B. Diabetes mellitus While OSA is associated with an increased risk of insulin resistance and metabolic syndrome, it is not a direct complication.
C. Nasal polyps Nasal polyps can contribute to breathing difficulties but are not a complication of OSA.
D. Heart failure OSA can lead to chronic hypoxia and increased cardiac workload, contributing to conditions such as hypertension, arrhythmias, and heart failure.

A. Apply intermittent suction for 20 to 30 seconds. B. Place the catheter in a location that is clean and dry for later use. C. Hold the suction catheter with the clean, nondominant hand. D. Use surgical asepsis when performing the procedure.

Correct Answer is D

Explanation

A. "Apply intermittent suction for 20 to 30 seconds." –
Suctioning should be applied intermittently for no more than 10 to 15 seconds to prevent hypoxia and mucosal damage.
B. "Place the catheter in a location that is clean and dry for later use." –
A suction catheter should not be reused once it has been used; it should be discarded after a single use to prevent infection.
C. "Hold the suction catheter with the clean, nondominant hand." –
The dominant hand should remain sterile and be used to control the suction catheter, while the nondominant hand is used to handle nonsterile equipment.
D. "Use surgical asepsis when performing the procedure." –
Nasotracheal suctioning is a sterile procedure because it involves direct access to the lower airway, requiring surgical asepsis to reduce the risk of infection.

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A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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