A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the
wound care procedure. Which of the following finding... [Show More] s indicate wound healing.
a. Erythema on the skin surrounding a client's wound
b. Deep red color on the center of the clients wound
c. Inflammation noted on the tissue edges of a client's wound
d. Increase in serosanguineous exudate from the clients wound (damaged capillaries)
Rationale: Leadership 7.0 pg 329:
- Stages of Wound Healing
- Inflammatory stage - beginning stage, also usually suggests infection
- Begins with the injury and lasts 3 to 6 days
- Effects to the wound: controlling bleeding with vasoconstriction and retraction of
blood vessels, and with clot formation. Delivering oxygen, WBCs, nutrients to the
area via blood supply. Hemostasis occurs along with fibrin formation. Macrophages
engulf microorganisms and cellular debris (phagocytosis).
- Proliferative stage
- Lasts the next 3 to 24 days
- Effects to the wound: replacing lost tissue with connective or granulated tissue or
collagen. Contracting the wound’s edges. Resurfacing of new epithelial cells. Healthy
granulation tissue does not bleed easily. Dark granulation tissue can be a sign of
infection, ischemia, or poor perfusion. In the final phase of the proliferative stage of
wound healing, epithelial cells resurface the injury.
- Maturation or remodeling stage
- Occurs after day 21 and involves that strengthening of the collagen scar and
restoration of a more normal appearance. It can take more than 1 year to complete,
depending on the extent of the original wound. When scar tissues are forming.
- Appearance:
- Note the color of open wounds.
- Red: healthy regeneration of tissue.
- Yellow: presence of purulent drainage and slough
- Black: presence of eschar that hinders healing and requires removal.
2. A nurse received change of shift report at 0700 for four clients. Which of the following actions should the
nurse perform first?
a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart. -
(fast-acting insulin...usually takes effect after 15 minutes)
b. Administer pain medication to a client who has rheumatoid arthritis and received the last
dose at 0400.
c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should
the nurse assign to the newly licensed nurse?
a. A client who has multiple sclerosis and ataxia - (normal finding for someone that has multiple
sclerosis= most stable - showed up on online practice tests)
b. A client who has brain tumor and is admitted for chemotherapy ← dead
c. A client who has guillain-barre syndrome and a tracheostomy -unstable
d. A client who sustained a concussion and is being monitored for complication -unstable
4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the
client indicates an understanding of the teaching?
a. “Once I sign my living will, a family member must co-sign it”
b. “I will wait until I have a serious health problems to sign my advance directives”
c. “My doctor will need to provide approval for the decisions outlines in my living will
d. “My durable power of attorney for health care is part of my advance directives”-durable power
of will and living will are components of advance directives.
Rationale: Leadership 7.0 page 38
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