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

A WBC count of 20,000/mm3 indicates infection and inflammation, which is expected in osteomyelitis. Long-term IV antibiotic therapy is a common treatment for osteomyelitis and may require a referral to avoid peripherl thrombophlebitis. Furosemide is a diuretic that may be prescribed for clients who have fluid retention or hypertension, which are not related to osteomyelitis. A HbA1c of 6% indicates good glycemic control for a client with type 2 diabetes mellitus, which can help prevent complications and infections.

A. Check the client's gag reflex. B. Inform the client they might experience a low-grade fever. C. Provide the client with sips of water. D. Instruct the client to report bleeding.

Correct Answer is A

Explanation

The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.

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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 providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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