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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Information regarding organ donation is not part of advance directives, but rather a separate document that the client can sign to indicate their willingness to donate their organs or tissues after death. The nurse should inform the client about the option and process of organ donation, but not include it in the advance directives.
Choice B reason: Instructions regarding treatments the client desires or does not desire is part of advance directives, as it allows the client to express their preferences and values regarding their health care in case they become unable to make decisions for themselves. The nurse should help the client understand the benefits and risks of different treatments and document their choices in the advance directives.
Choice C reason: Information regarding the disposition of the client's body upon death is not part of advance directives, but rather a personal or legal matter that the client can arrange with their family or attorney. The nurse should respect the client's wishes regarding their body after death, but not include it in the advance directives.
Choice D reason: A form with directions for contacting next of kin is not part of advance directives, but rather a routine document that the client can fill out when they are admitted to the facility. The nurse should obtain the client's contact information and emergency contacts, but not include it in the advance directives.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as hospice care provides comprehensive and compassionate care for clients who have a life expectancy of six months or less. Hospice care involves a team of health care professionals, such as physicians, nurses, social workers, chaplains, and volunteers, who address the physical, emotional, social, and spiritual needs of the client and their family.
Choice B reason: This statement is incorrect, as hospice care is not intended for clients at various stages of chronic illness. Hospice care is only for clients who are terminally ill and have decided to forego curative or aggressive treatments.
Choice C reason: This statement is incorrect, as hospice care does not prolong the life expectancy of clients who are terminally ill. Hospice care focuses on improving the quality of life and comfort of the client, not on extending their life span.
Choice D reason: This statement is incorrect, as hospital access is still available for clients who are in hospice care. Hospice care can be provided in various settings, such as the client's home, a hospice facility, a nursing home, or a hospital. Clients who are in hospice care can still be admitted to the hospital if they need acute care or symptom management.
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