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?

Wound tissue firm to palpation

Dry brown eschar

Light yellow exudate

Dark red granulation tissue

Answer and Explanation

The Correct Answer is D

A pressure ulcer is a localized injury to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture.

Granulation tissue is new connective tissue and blood vessels that form on the surface of a wound during healing . It is usually dark red or pink in color and moist in appearance . Wound tissue that is firm to palpation may indicate edema, inflammation, or infection . Dry brown eschar is dead tissue that covers the wound and prevents healing . Light yellow exudate is a sign of wound infection or necrosis .

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Correct Answer is B

Explanation

Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.

A. Bradycardia B. Hypertension C. Chills D. Back pain

Correct Answer is D

Explanation

Back pain is a common symptom of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks and destroys the donor's red blood cells. Other symptoms include fever, chills, dyspnea, chest pain, hypotension, tachycardia, hemoglobinuria, and jaundice. A hemolytic transfusion reaction is a medical emergency that requires immediate intervention.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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