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
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 .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A high WBC count (leukocytosis) indicates an inflammatory response to an infection, such as pneumonia. The nurse should expect to see this value in a client who has pneumonia and monitor the client for signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). The other values are within normal or expected ranges for a client who has pneumonia.
Correct Answer is B
Explanation
A chest physiotherapy vest is a device that delivers high-frequency chest wall oscillation to loosen and mobilize mucus from the airways . This helps improve lung function and prevent respiratory infections in patients with cystic fibrosis, who have thick and sticky mucus production . A peak flow meter is used to measure the peak expiratory flow rate, which reflects the degree of airway obstruction in patients with asthma .
An NG tube with suction apparatus is used to decompress the stomach and remove gastric contents in patients with bowel obstruction, paralytic ileus, or gastroparesis . A chest tube with a drainage system is used to remove air or fluid from the pleural space in patients with pneumothorax, hemothorax, or pleural effusion .
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