211.
A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed ispale. The nurse interprets this finding as a possible indication that:
A) The wound is healthyB) The wound is improvingC) Necrotic tissue is presentD) The client's hemoglobin level is lowANS: DFeedback: CORRECTRationale: The color of a wound provides information about vascular supply, infection, the presence of
healthy or necrotic tissue, and nutritional status. A pale wound bed may reflect a low hemoglobin value.
Healthy full-thickness wounds have a granular beefy-red appearance. Necrotic tissue is white, yellow,
gray, or black.
Pseudomonas
infection can produce greenish drainage in a wound bed.
Test-Taking Strategy:
Use the process of elimination. Eliminate the options that are comparable or alike
(wound is healthy and wound is improving). To select from the remaining options, focus on the word
"pale" in the question. This will direct you to the correct option. Review the characteristics of pressure
ulcers if you had difficulty with this question.
References:
Ignatavicius, D., & Workman, M. (2010).
Medical-surgical nursing: Patient-centered
collaborative care
(6th ed., pp. 489, 43). St. Louis: Saunders.
Perry, A., & Potter, P. (2010).
Clinical nursing skills & techniques
(7th ed., p. 471). St. Louis: Mosby.
Cognitive Ability:
Evaluating
Client Needs:
Physiological Integrity
Integrated Process:
Nursing Process/Evaluation
Content Area:
Adult Health/Integumentary
Points Earned:
1.0/1.0
Correct Answer(s):
D
212.A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately:
exposed skin
appropriate clothing. If contact with poison ivy is suspected, symptoms may be averted by immediately
rinsing the skin for 15 minutes with running water to remove the resin before skin penetration occurs.
The
client is also instructed to remove clothing carefully to avoid skin contact. Although a topical over-
thecounter
corticosteroid may relieve some of the discomfort of the poison ivy rash, this is not the action that
needs to be taken immediately. Contacting the physician and coming to the emergency department for
treatment are unnecessary.
Test-Taking Strategy:
Note the strategic word “immediately.” Eliminate the options that are comparable
or
alike (contacting the physician and reporting to the emergency department). Next note that the question
involves an individual who may have been exposed to poison ivy; showering will help remove the resin.
