A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

Increase in serosanguineous exudate from a client's wound

Deep red color on the center of a client's wound

Erythema on the skin surrounding a client's wound

Inflammation noted on the tissue edges of a client's wound

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the correct choice because an increase in serosanguineous exudate (a mixture of blood and clear fluid) from a client's wound indicates infection, inflammation, or trauma to the wound. This is a sign of wound deterioration, not healing.

Choice B reason: This is the correct choice because a deep red color on the center of a client's wound indicates granulation tissue, which is new tissue that forms during the healing process. Granulation tissue fills the wound bed and provides a foundation for epithelialization (the growth of new skin over the wound).

Choice C reason: This is not the correct choice because erythema (redness) on the skin surrounding a client's wound indicates irritation, inflammation, or infection of the skin. This is a sign of wound complication, not healing.

Choice D reason: This is not the correct choice because inflammation on the tissue edges of a client's wound indicates infection, trauma, or necrosis (death) of the tissue. This is a sign of wound impairment, not healing.

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Correct Answer is C

Explanation

Choice A reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use decimals or trailing zeros when writing doses, as they can be misread or mistaken for larger doses. For example, 10.0 mg could be read as 100 mg.

Choice B reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MSO4 could be confused with magnesium sulfate (MgSO4).

Choice C reason: This is the correct way to transcribe a verbal prescription. The nurse should write the full name of the drug, the dose, the route, the frequency, and the indication for use. The nurse should also use standard abbreviations that are clear and unambiguous. For example, IV means intravenous, q4h means every 4 hours, and prn means as needed.

Choice D reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MS could be confused with morphine sulfate or magnesium sulfate. The nurse should also use standard abbreviations for the route and frequency, not words like every or prn.

A. The client's code status B. The client's vital signs C. The client's name D. A prescribed consultation

Correct Answer is C

Explanation

Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.

Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.

Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.

Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.

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A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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