A nurse is assessing a patient who has a wound that is healing by first intention. What findings should the nurse expect?

Granulation tissue forming at the bottom of the wound bed.

Wound was contaminated at the time of injury.

Healing of the wound is prolonged.

Skin edges of the wound are sutured closed.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.

Choice B rationale

A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.

Choice C rationale

Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.

Choice D rationale

In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.

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Correct Answer is C

Explanation

Choice A rationale

Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.

Choice B rationale

Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.

Choice C rationale

Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.

Choice D rationale

Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.

Correct Answer is ["5.6"]

Explanation

Step 1: Convert the toddler’s weight from pounds to kilograms. 1 kg is approximately 2.2 lb. So, 33 lb ÷ 2.2 = 15 kg.

Step 2: Calculate the total daily dose of amoxicillin. The prescribed dose is 30 mg/kg/day. So, 30 mg/kg/day × 15 kg = 450 mg/day.

Step 3: Since the dose is divided into 2 equal doses every 12 hours, each dose will be half of the total daily dose. So, 450 mg/day ÷ 2 = 225 mg/dose.

Step 4: Calculate the volume of the suspension to administer per dose. The available suspension is 200 mg/5 mL. So, (225 mg/dose ÷ 200 mg) × 5 mL = 5.625 mL/dose. Therefore, the nurse should administer approximately 5.6 mL of the amoxicillin suspension per dose.

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A nurse is assessing a patient who has a wound that is healing by first intention. What findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient in a long-term care facility who is receiving enteral feedings via a nasogastric (NG) tube.What action should the nurse take before administering the tube feeding?

Correct Answer is C

Explanation

A nurse is preparing to administer amoxicillin 30 mg/kg/day in 2 equally divided doses every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer per dose?

Correct Answer is ["5.6"]

Explanation

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