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 A

Explanation

The nurse should instruct the client to use a 10-mL syringe or larger to flush the PICC line with normal saline or heparin solution, as prescribed, to prevent occlusion and thrombosis. The other options are incorrect because they may cause complications such as infection, phlebitis, or bleeding.

A. Instruct the client to cough as the catheter is inserted. B. Place the head of the client's bed lower than the foot. C. Cleanse the site with a hydrogen peroxide solution. D. Confirm the correct position of the line by obtaining a blood sample.

Correct Answer is D

Explanation

The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.

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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 A

Explanation

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Correct Answer is D

Explanation

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