A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
Dry brown eschar
Wound tissue firm to palpation
Light yellow exudate
Dark red granulation tissue
The Correct Answer is D
A. Dry brown eschar is a sign of necrotic tissue, which indicates that the wound is not healing properly. Eschar needs to be removed for proper healing to occur.
B. Wound tissue firm to palpation is not a typical sign of healing. Healing tissue tends to be softer, while firm tissue could indicate fibrosis or an abnormal healing process.
C. Light yellow exudate can indicate the presence of infection or the early stages of healing, but it is not as specific a sign of healing as granulation tissue. Granulation tissue is a more definitive sign of healing.
D. Dark red granulation tissue is a sign of healthy healing tissue. It consists of new blood vessels and is an indication that the wound is in the proliferative phase of healing, which is a positive sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Mouth sores can be a common side effect of chemotherapy, but acupuncture is generally not contraindicated for mouth sores. In fact, acupuncture may help alleviate some of the discomfort associated with this side effect.
B. Lymphedema is a contraindication for acupuncture because the insertion of needles in areas with compromised lymphatic flow could worsen the condition. It is important to avoid any invasive procedures in areas where the lymphatic system is at risk for further damage.
C. Headaches are a common side effect of chemotherapy and can be managed with acupuncture. Acupuncture is often used to treat various types of headaches, including those associated with chemotherapy.
D. Urticaria (hives) is not a contraindication to acupuncture. However, the nurse should ensure that the client does not have an active allergic reaction at the acupuncture site, but generally, acupuncture can be safely performed in individuals with urticaria.
Correct Answer is A
Explanation
A. A decrease in blood pressure is the correct finding that indicates telmisartan has been effective. Telmisartan is an angiotensin II receptor blocker (ARB) used primarily to treat hypertension, and its effectiveness is typically measured by a reduction in blood pressure.
B. A respiratory rate of 16/min is within the normal range for adults and does not indicate the effectiveness of telmisartan, as the medication primarily affects blood pressure and not respiratory function.
C. A blood glucose of 110 mg/dL is within the normal range and does not directly reflect the effectiveness of telmisartan. While ARBs like telmisartan may have some effect on glucose metabolism, blood glucose levels are not the primary indicator of its effectiveness.
D. An increase in urinary output is not directly related to the effectiveness of telmisartan. While ARBs can have some mild diuretic effects, the primary expected outcome is a reduction in blood pressure, not an increase in urine output.
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