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 D

Explanation

Valsartan is an angiotensin II receptor blocker that lowers blood pressure by blocking the vasoconstrictive and aldosterone-secreting effects of angiotensin II. Loweringblood pressure reduces the workload of the heart and improves cardiac function in patients with heart failure . Decreased urinary output, increased heart rate, and increased potassium level are not expected outcomes of valsartan therapy and may indicate worsening of heart failure or adverse effects of the medication.

A. Inspect the feet every other day. B. Apply lotion between the toes. C. Soak the feet twice a day. D. Trim toenails straight across.

Correct Answer is D

Explanation

The nurse should instruct the client to trim toenails straight across to prevent ingrown toenails and infection. The nurse should also advise the client to inspect the feet daily for any signs of injury or ulceration, to avoid applying lotion between the toes as this can cause maceration and fungal growth, and to avoid soaking the feet as this can dry out the skin and increase the risk of injury.

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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 assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is D

Explanation

A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include?

Correct Answer is D

Explanation

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