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

Granulation tissue forming at the bottom of the wound bed.

Healing of the wound is prolonged.

Skin edges of the wound are sutured closed.

Wound is contaminated at the time of injury

Answer and Explanation

The Correct Answer is C

A) Granulation tissue forming at the bottom of the wound bed:
Granulation tissue typically forms in wounds that heal by secondary intention. This type of healing occurs when the wound edges are not approximated (e.g., a large or open wound), and new tissue must form to fill the gap. In primary intention healing, the wound edges are well approximated, and granulation tissue is not the hallmark of the healing process, although some may appear early on.

B) Healing of the wound is prolonged:
Wounds healing by primary intention generally heal more quickly than those healing by secondary intention. In primary intention, the wound edges are approximated with sutures, staples, or adhesive, allowing for a faster and more efficient healing process. Therefore, prolonged healing is not expected with primary intention]

C) Skin edges of the wound are sutured closed:
This is the correct finding for a wound healing by primary intention. Primary intention healing occurs when the wound edges are brought together (approximated) and secured with sutures, staples, or adhesive strips. This method promotes faster healing and minimal scarring because the tissue is directly aligned.

D) Wound is contaminated at the time of injury:
Wounds that heal by primary intention are generally clean and not contaminated. If a wound is contaminated or infected at the time of injury, it is more likely to heal by secondary intention, where the tissue must fill in from the base upwards, which takes longer and may result in more scarring.

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Correct Answer is C

Explanation

A) "I will wear earphones during this test":
This statement is incorrect. The Rinne test is a hearing test used to compare air conduction to bone conduction of sound. It is performed by placing a vibrating tuning fork near the ear canal (for air conduction) and then on the mastoid bone behind the ear (for bone conduction). Earphones are not used in this test.

B) "A small probe is placed inside my ear":
This statement is incorrect. A probe is typically used for other types of hearing tests, such as tympanometry or an auditory brainstem response (ABR) test, not the Rinne test. The Rinne test involves using a tuning fork, not a probe, and the tuning fork is placed near the ear canal (for air conduction) and on the mastoid bone (for bone conduction).

C) "A tuning fork is placed on my head":
This statement is correct. In the Rinne test, the tuning fork is initially struck to produce sound and then placed on the mastoid bone (behind the ear) to test bone conduction. Afterward, the vibrating tuning fork is moved to the front of the ear canal to test air conduction. The purpose of the test is to compare these two types of conduction. If air conduction is better than bone conduction, this suggests normal hearing, while equal or better bone conduction can indicate conductive hearing loss.

D) "Small electrodes are placed on my scalp":
This statement is incorrect. Electrodes on the scalp are typically used in an electroencephalogram (EEG) or other neurodiagnostic tests, not the Rinne test. The Rinne test focuses on hearing and does not require the use of electrodes. It uses a tuning fork to assess how well sound travels through air and bone.

A. Hypokalemia B. Bleeding C. Bradycardia D. Seizures

Correct Answer is C

Explanation

A) Hypokalemia:
Hypokalemia (low potassium levels) is not a common adverse effect of labetalol. While some medications, such as diuretics, can lead to hypokalemia, labetalol does not typically affect potassium levels directly. Instead, labetalol's primary effects are on blood pressure and heart rate.

B) Bleeding:
Bleeding is not a typical adverse effect of labetalol. Labetalol is a beta blocker that works by blocking beta-adrenergic receptors, which lowers heart rate and blood pressure. It does not interfere with blood clotting or platelet function, so bleeding would not be a concern unless the patient is on other medications that affect coagulation (such as anticoagulants).

C) Bradycardia:
Bradycardia, or a slow heart rate, is a well-known and common adverse effect of beta blockers like labetalol. Labetalol works by blocking the beta-1 adrenergic receptors in the heart, which can reduce heart rate and lower blood pressure. In some individuals, this can result in bradycardia, which could lead to symptoms like dizziness, fatigue, and fainting.

D) Seizures:
Seizures are not a typical adverse effect of labetalol. Although central nervous system effects like dizziness or fatigue can occur due to the blood pressure-lowering effects, seizures are not commonly associated with this medication.

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

Nursing Test Bank

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Explanation

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Correct Answer is C

Explanation

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