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 C

Explanation

Correct answer: C) Alginate

Rationale: Alginate is a type of dressing that is derived from seaweed and forms a gel-like substance when in contact with wound exudate. It is highly absorbent and can handle moderate to large amounts of drainage. It also provides a moist wound environment and supports autolytic debridement of slough and eschar. It is suitable for wounds with depth, such as stage 3 or 4 pressure ulcers.

Incorrect options:

A) Hydrocolloid - This is a type of dressing that has an adhesive outer layer and an inner layer that forms a gel when in contact with wound fluid. It is occlusive and waterproof and provides a moist wound environment. It is suitable for wounds with minimal to moderate drainage, such as stage 2 pressure ulcers or partial-thickness burns. It is not recommended for wounds with depth, as it may cause maceration of the surrounding skin.

B) Hydrogel - This is a type of dressing that consists of water or glycerin-based gels that are available in sheets, gauze, or impregnated into other types of dressings. It provides moisture to dry wounds and facilitates autolytic debridement. It is suitable for wounds with minimal drainage, such as stage 2 pressure ulcers or partial-thickness burns. It is not recommended for wounds with moderate to large amounts of drainage, as it may cause maceration or leakage.

D) Transparent film - This is a type of dressing that consists of a thin sheet of polyurethane with an adhesive coating that allows the exchange of oxygen and moisture vapor but not bacteria or water. It provides a moist wound environment and facilitates autolytic debridement. It is suitable for wounds with minimal drainage, such as stage 1 pressure ulcers or superficial abrasions. It is not recommended for wounds with depth or moderate to large amounts of drainage, as it may cause maceration or leakage.

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?

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Naxlex Comprehensive Predictor Exams

A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is 4 cm in length, 3 cm in width, and 2 cm in depth. The wound bed is 80% granulation tissue and 20% slough. Which type of dressing should the nurse use for this wound?

Correct Answer is C

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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