A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

Muscular strength assessment

Sensation assessment

Sleep assessment

Pulse oximetry assessment

Answer and Explanation

The Correct Answer is D

A. Muscular strength assessment: While muscular strength is important for overall mobility and health, it is not a key factor in wound healing. Wound healing is primarily influenced by oxygenation, perfusion, and nutrition.

B. Sensation assessment: While sensation is important in patients with conditions like diabetes (due to the risk of neuropathy and unnoticed wounds), it is not the most relevant assessment for determining wound healing.

C. Sleep assessment: Adequate rest is beneficial for healing, but sleep assessment is not the primary factor that determines wound healing. Other physiological factors play a greater role.

D. Pulse oximetry assessment: Oxygenation is a critical factor in wound healing. Low oxygen levels impair tissue repair, increase infection risk, and slow cell regeneration. Pulse oximetry assesses the oxygen levels in the blood, making it the most relevant assessment for wound healing.

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Correct Answer is C

Explanation

A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.

B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.

C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.

D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.

A. Pleural effusion B. Hypoxemia C. Dysphagia D. Apnea

Correct Answer is B

Explanation

A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.

B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.

C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.

D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.

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A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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