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 {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

The client is at risk for developing constipation due to opioid use.

Rationale:

Opioid Use → Constipation: Oxycodone, like other opioids, slows gastrointestinal motility, leading to constipation. This is a common postoperative concern, especially in clients with reduced mobility after a hip arthroplasty.
- Confusion – No signs of mental status changes or factors like electrolyte imbalances.
- Pressure Injuries – While immobility increases risk, this is not directly related to the provided findings.
- Hypoglycemia – Blood glucose is normal, and there’s no IV dextrose mentioned.
- Dysrhythmias – Potassium and sodium levels are within normal limits, reducing electrolyte-related cardiac risks.

A. "Place the head of the bed flat before using the incentive spirometer." B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." C. "Use the incentive spirometer every 3 hours while awake." D. "Breathe in through your nose when using the incentive spirometer."

Correct Answer is B

Explanation

A. "Place the head of the bed flat before using the incentive spirometer." The client should be in a semi-Fowler’s or high-Fowler’s position (sitting upright) to maximize lung expansion.
B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." Holding the breath allows for maximum lung expansion and helps prevent atelectasis (lung collapse).
C. "Use the incentive spirometer every 3 hours while awake." The incentive spirometer should be used every 1 to 2 hours while awake to promote lung expansion and prevent complications such as pneumonia.
D. "Breathe in through your nose when using the incentive spirometer." The client should inhale deeply through the mouth, not the nose, to ensure proper lung inflation.

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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

A nurse is caring for a client. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing dropdowndue todropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

A nurse is providing preoperative teaching about using an incentive spirometer for a client. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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