A nurse is assessing a client who has a pressure ulcer.

Which of the following findings should the nurse expect as an indication the wound is healing?

Dark red granulation tissue.

Light yellow exudate.

Dry brown eschar.

Wound tissue firm to palpation.

Answer and Explanation

The Correct Answer is A

Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process.
The presence of dark red granulation tissue is a sign that the wound is healing.
B. Light yellow exudate: Light yellow exudate may indicate the presence of infection and is not a sign of healing.
C. Dry brown eschar: Dry brown eschar is dead tissue that needs to be removed for the wound to heal properly.
D. Wound tissue firm to palpation: Wound tissue firm to palpation is not a specific sign of healing.

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Correct Answer is A

Explanation

Place two-bed pillows between the legs when in bed.
To prevent hip dislocation after total hip arthroplasty, the nurse should place two-bed pillows between the client’s legs when in bed.
This helps maintain proper alignment and prevent the hip from dislocating.
Choice B is incorrect because leaning forward when attempting to stand can increase the risk of hip dislocation.
Choice C is incorrect because removing the wedge device when turning can increase the risk of hip dislocation.
Choice D is incorrect because elevating the knees higher than the hips when sitting can increase the risk of hip dislocation.

A. 2.5 mL. B. 25 mL. C. 2.05 mL. D. 2.25 mL.

Correct Answer is A

Explanation

Let’s break down the problem step by step:

Step 1: Convert the client’s weight from pounds (lb) to kilograms (kg). We know that 1 kg = 2.2 lbs. So, we have: 220 lb ÷ 2.2 = 100 kg

Step 2: Calculate the total amount of naloxone needed. The doctor ordered 10 mcg/kg, and the client weighs 100 kg. So, we have: 10 mcg/kg × 100 kg = 1000 mcg

Step 3: Convert micrograms (mcg) to milligrams (mg). We know that 1 mg = 1000 mcg. So, we have: 1000 mcg ÷ 1000 = 1 mg

Step 4: Calculate the volume of naloxone solution needed. The available naloxone solution is 0.4 mg/mL. So, we have: 1 mg ÷ 0.4 = 2.5 mL

So, the nurse should administer 2.5 mL of naloxone. Since we are asked to round off to the nearest tenth, the final answer remains 2.5 mL.

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A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?

Correct Answer is A

Explanation

A nurse is preparing to administer naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lb. The amount available is 0.4 mg/mL. How many mL should the nurse administer? (round off to the nearest tenth)

Correct Answer is A

Explanation

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A nurse is assessing a client who has a pressure ulcer.

Which of the following findings should the nurse expect as an indication the wound is healing?