Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Hemostasis

Inflammatory phase

Maturation phase

Proliferation phase

Answer and Explanation

The Correct Answer is D

Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale: A physician's order is typically required for a digital removal of a fecal impaction.
Choice B rationale: Using a lubricated index finger to break up some of the mass and remove it is a correct step in the procedure.
Choice C rationale: Sterile gloves are not required for a digital removal of a fecal impaction. Clean gloves are generally sufficient.
Choice D rationale: The mass may need to be broken up into smaller pieces for removal, rather than being removed as a whole.
Choice E rationale: The patient is usually positioned in a side-lying position for comfort and accessibility during the procedure.

A. Purplish-colored stoma B. Shiny, moist stoma C. Stoma oozing red drainage D. "Budded" stoma

Correct Answer is A

Explanation

Choice A rationale: A purplish-colored stoma may indicate compromised blood supply and should be reported to the provider.
Choice B rationale: A shiny, moist stoma is a healthy characteristic of a colostomy. Choice C rationale: Stoma oozing red drainage is a normal finding after colostomy surgery.
Choice D rationale: "Budded" stoma is not a recognized term related to colostomy assessment.

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Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

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When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?