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

The nurse should instruct the client to obtain sterile lancets for blood glucose monitoring.
Lancets are small needles used to prick the skin to obtain a blood sample for testing blood glucose levels.
Choice B is wrong because compression stockings are not necessary for blood glucose monitoring.
Choice C is wrong because toenail clippers are not necessary for blood glucose monitoring.
Choice D is wrong because a hand mirror is not necessary for blood glucose monitoring.

A. "I will perform strength-building arm exercises using a 15-pound weight.". B. "l will have to wait 2 months before additional saline can be added to my breast expander.". C. "I will keep my left arm flexed at the elbow as much as possible.". D. "I should expect less than 25 mL of secretions per day in the drainage devices.".

Correct Answer is D

Explanation

“I should expect less than 25 mL of secretions per day in the drainage devices.” After a mastectomy with breast reconstruction using a tissue expander, you may go home with drains in your chest to remove extra fluid.

Choice A is wrong because performing strength-building arm exercises using a 15-pound weight is not recommended.
Choice B is wrong because waiting 2 months before additional saline can be added to the breast expander is not accurate.
Choice C is wrong because keeping the left arm flexed at the elbow as much as possible is not recommended.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching about blood glucose monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

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?