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 A
Explanation
Choice A reason: This is the correct choice because autonomy is the ethical principle that respects the client's right to make their own decisions about their health care. The nurse should honor the client's wishes and preferences, even if they differ from the nurse's or the provider's. The nurse should not force or coerce the client to accept blood transfusions, as this would violate their autonomy.
Choice B reason: This is not the correct choice because fidelity is the ethical principle that requires the nurse to be faithful and loyal to the client and their agreement. The nurse should keep their promises and commitments, and act in the best interest of the client. The nurse should not administer blood transfusions to the client without their consent, as this would breach their trust and fidelity.
Choice C reason: This is not the correct choice because justice is the ethical principle that ensures fair and equal treatment for all clients. The nurse should distribute resources and services according to the client's needs and rights, and avoid any discrimination or bias. The nurse should not administer blood transfusions to the client against their will, as this would disregard their justice.
Choice D reason: This is not the correct choice because veracity is the ethical principle that obliges the nurse to be honest and truthful with the client. The nurse should provide accurate and complete information, and disclose any errors or risks. The nurse should not administer blood transfusions to the client without informing them, as this would violate their veracity.
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because checking on a client whose telemetry monitor is continuously beeping is a task that requires nursing judgment and assessment skills. The nurse should not delegate this task to the AP, but rather perform it themselves or notify the health care provider.
Choice B reason: This is the correct choice because tagging a malfunctioning piece of equipment as broken is a task that does not involve direct client care or clinical decision making. The nurse can delegate this task to the AP, who can follow the facility's policy and procedure for reporting and removing faulty equipment.
Choice C reason: This is not the correct choice because determining whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula is a task that involves administering medication and monitoring the client's oxygenation status. The nurse should not delegate this task to the AP, but rather perform it themselves and document the results.
Choice D reason: This is not the correct choice because instructing a client about the use of an incentive spirometer is a task that involves providing client education and evaluating the client's understanding and compliance. The nurse should not delegate this task to the AP, but rather perform it themselves and document the outcomes.
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