A nurse is assessing a client who has a wound on the abdomen. The nurse observes that the wound edges are approximated, there is minimal drainage, and granulation tissue is visible. How should the nurse document this wound?

Partial-thickness wound

Full-thickness wound

Primary intention wound

Secondary intention wound

Answer and Explanation

The Correct Answer is C

Correct answer: C) Primary intention wound

Rationale: A primary intention wound is one that heals by epithelialization, with minimal tissue loss and scarring. The wound edges are approximated (closed), either naturally or by surgical means, and there is minimal drainage and inflammation. Granulation tissue is the new connective tissue that forms on the wound bed, indicating healing.

Incorrect options:

A) Partial-thickness wound - This is a wound that involves damage to the epidermis and part of the dermis, such as an abrasion or a blister. It heals by regeneration, with minimal scarring.

B) Full-thickness wound - This is a wound that involves damage to the epidermis, dermis, and underlying structures, such as a pressure ulcer or a surgical incision. It heals by granulation, contraction, and epithelialization, with significant scarring.

D) Secondary intention wound - This is a wound that heals by granulation, contraction, and epithelialization, with significant tissue loss and scarring. The wound edges are not approximated (open), either due to infection, trauma, or chronicity, and there is copious drainage and inflammation.

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Correct Answer is B

Explanation

Correct answer: B) Obtain a wound culture and sensitivity

Rationale: The nurse should first obtain a wound culture and sensitivity to identify the causative organism and the appropriate antibiotic therapy for the client's wound infection. The nurse should use sterile technique and collect the specimen from the wound bed after cleansing the wound with normal saline.

Incorrect options:

A) Apply compression bandages to the affected leg - Compression therapy is indicated for clients with venous leg ulcers to improve venous return and reduce edema, but it is not the first priority in this case. The nurse should first address the infection before applying compression bandages.

C) Administer prescribed analgesics and antipyretics - Administering analgesics and antipyretics may help to relieve the client's pain and fever, but it does not treat the underlying cause of the infection. The nurse should first obtain a wound culture and sensitivity before administering medications.

D) Elevate the affected leg above the level of the heart - Elevating the affected leg may help to reduce edema and improve blood flow, but it does not address the infection. The nurse should first obtain a wound culture and sensitivity before elevating the leg.

A. 2,100 mL B. 4,200 mL C. 8,400 mL D. 16,800 mL

Correct Answer is D

Explanation

Correct answer: D) 16,800 mL

Rationale: The Parkland formula is used to calculate the fluid resuscitation for burn clients. It states that the client should receive 4 mL of lactated Ringer's solution per kg of body weight per percentage of TBSA burned in the first 24 hours after the injury. Half of this amount should be given in the first 8 hours, and the remaining half should be given in the next 16 hours. Therefore, for this client, the calculation is as follows:

4 mL x 70 kg x 30% = 8,400 mL in the first 24 hours

8,400 mL / 2 = 4,200 mL in the first 8 hours

8,400 mL - 4,200 mL = 4,200 mL in the next 16 hours

Incorrect options:

A) 2,100 mL - This is half of the amount that should be given in the first 8 hours.

B) 4,200 mL - This is the amount that should be given in the first 8 hours or in the next 16 hours.

C) 8,400 mL - This is half of the amount that should be given in the first 24 hours.

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A nurse is assessing a client who has a wound on the abdomen. The nurse observes that the wound edges are approximated, there is minimal drainage, and granulation tissue is visible. How should the nurse document this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client is admitted to the hospital with a burn injury that covers 30% of the total body surface area (TBSA). The client's weight is 70 kg. Using the Parkland formula, how much fluid should the client receive in the first 24 hours after the injury?

Correct Answer is D

Explanation

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