A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:

Primary intention

Secondary intention

Tertiary intention

Quaternary intention

Answer and Explanation

The Correct Answer is A

Answer: A

Primary intention is a type of wound healing that occurs when the edges of the wound are well approximated and there is minimal tissue loss or infection. It results in minimal scarring and fast healing.

B. Secondary intention is a type of wound healing that occurs when the edges of the wound are not approximated or there is extensive tissue loss or infection. It results in granulation tissue formation, contraction, and epithelialization. It takes longer to heal and may result in scarring and infection.

C. Tertiary intention is a type of wound healing that occurs when there is a delay in closing the wound or when the wound is intentionally left open for drainage or debridement. It results in less scarring than secondary intention but more than primary intention.

D. Quaternary intention is not a valid term for wound healing.

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Correct Answer is A

Explanation

Answer: A.

The presence of necrotic tissue increases the risk of infection by providing a medium for bacterial growth and impairing wound healing. Necrotic tissue should be debrided to promote wound healing.

B. The use of hydrocolloid dressing is not a risk factor for infection. Hydrocolloid dressings are occlusive and adhesive, which create a moist environment that facilitates wound healing and prevents bacterial contamination.

C. The frequency of wound irrigation is not a risk factor for infection. Wound irrigation is done to cleanse the wound and remove debris and exudate. It should be done gently and with sterile solution to avoid trauma and contamination.

D. The application of topical antibiotics is not a risk factor for infection. Topical antibiotics are used to treat or prevent infection in some wounds. They should be used with caution and as prescribed, as overuse may lead to resistance or allergic reactions.

A. The wound has increased in size B. The wound has decreased in drainage C. The wound has increased in pain D. The wound has decreased in granulation tissue

Correct Answer is B

Explanation

Answer: B

The wound has decreased in drainage is an outcome that would indicate that NPWT is successful. NPWT is a type of therapy that uses a vacuum device to apply negative pressure to the wound, which removes excess fluid, debris, and infectious material from the wound bed. This reduces edema, inflammation, and bacterial load, and promotes blood flow, oxygenation, and granulation tissue formation.

A. The wound has increased in size is an outcome that would indicate that NPWT is unsuccessful or harmful. NPWT should not cause wound enlargement, as this may indicate tissue damage, infection, or poor healing.

C. The wound has increased in pain is an outcome that would indicate that NPWT is unsuccessful or harmful. NPWT should not cause excessive pain, as this may indicate tissue damage, infection, or poor healing.

D. The wound has decreased in granulation tissue is an outcome that would indicate that NPWT is unsuccessful or harmful. NPWT should promote granulation tissue formation, as this indicates healthy wound healing.

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A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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