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 C

Explanation

An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.

Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.

A. Platelets 95,000/mm B. MCT 42% C. WBC count 8,000/mm D. INR of 1.6

Correct Answer is A

Explanation

A platelet count of 95,000/mm is below the normal range of 150,000 to 400,000/mm and indicates thrombocytopenia, which increases the risk of bleeding during surgery. The nurse should report this value to the surgeon and anticipate interventions such as transfusion of platelets or postponement of surgery. The other values are within normal limits and do not require immediate attention.

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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 teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

Correct Answer is A

Explanation

A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

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