A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?
Translucent, red tissue
Soft, yellow tissue
Stringy, white tissue
Thick, black tissue
The Correct Answer is A
A. Translucent, red tissue Granulation tissue is red or pink due to increased blood supply and is a sign of healing.
B. Soft, yellow tissue This describes slough, which consists of dead tissue and debris that may delay wound healing.
C. Stringy, white tissue This could indicate fibrin or slough, which may require debridement.
D. Thick, black tissue This describes eschar, which is necrotic (dead) tissue and needs removal for proper wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Consult the social worker to speak with the client about support groups. While a social worker can be a valuable resource, advocacy involves the nurse directly supporting the client rather than referring them to another professional as the primary action.
B. Help the client make decisions about their treatment by providing them with your opinions. Advocacy means ensuring the client has accurate, unbiased information to make informed decisions, not influencing them with personal opinions.
C. Provide the client with a computer to look up questions they have about their diagnosis. While access to information is important, the nurse should provide evidence-based resources and ensure the client receives accurate, professional guidance.
D. Avoid discussing alternative treatments that may have the potential to harm the client. Advocacy includes ensuring the client is aware of safe and effective treatment options while protecting them from misinformation or potentially harmful alternatives.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The client is at risk for developing constipation due to opioid use.
Rationale:
-
Opioid Use → Constipation: Oxycodone, like other opioids, slows gastrointestinal motility, leading to constipation. This is a common postoperative concern, especially in clients with reduced mobility after a hip arthroplasty.
- Confusion – No signs of mental status changes or factors like electrolyte imbalances.
- Pressure Injuries – While immobility increases risk, this is not directly related to the provided findings.
- Hypoglycemia – Blood glucose is normal, and there’s no IV dextrose mentioned.
- Dysrhythmias – Potassium and sodium levels are within normal limits, reducing electrolyte-related cardiac risks.
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