A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Skin edges of the wound are sutured closed.

Wound is contaminated at the time of injury.

Granulation tissue forming at the bottom of the wound bed.

Healing of the wound is prolonged.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Wound healing by first intention involves the approximation of wound edges, often closed with sutures or staples, resulting in minimal scar formation.
Choice B rationale: Contamination at the time of injury is not characteristic of wounds healing by first intention.
Choice C rationale: Granulation tissue forming at the bottom of the wound bed is characteristic of wounds healing by second intention, not first intention.
Choice D rationale: Healing of the wound is typically quicker and involves less scarring in wounds healing by first intention compared to second intention.

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Correct Answer is B

Explanation

Choice A rationale: Inserting an indwelling urinary catheter is an invasive intervention and should be reserved for specific indications. It does not prevent skin breakdown.
Choice B rationale: Applying a moisture barrier ointment to the client's skin helps protect the skin from the harmful effects of urine and prevents breakdown.
Choice C rationale: Cleaning the client's skin and perineum with hot water after each episode of incontinence can lead to skin irritation and breakdown.
Choice D rationale: Checking the client's skin every 8 hours is not sufficient to prevent skin breakdown. Continuous assessment and prompt intervention are needed.

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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A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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