A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Muscular strength assessment
Sensation assessment
Sleep assessment
Pulse oximetry assessment
The Correct Answer is D
A. Muscular strength assessment: While muscular strength is important for overall mobility and health, it is not a key factor in wound healing. Wound healing is primarily influenced by oxygenation, perfusion, and nutrition.
B. Sensation assessment: While sensation is important in patients with conditions like diabetes (due to the risk of neuropathy and unnoticed wounds), it is not the most relevant assessment for determining wound healing.
C. Sleep assessment: Adequate rest is beneficial for healing, but sleep assessment is not the primary factor that determines wound healing. Other physiological factors play a greater role.
D. Pulse oximetry assessment: Oxygenation is a critical factor in wound healing. Low oxygen levels impair tissue repair, increase infection risk, and slow cell regeneration. Pulse oximetry assesses the oxygen levels in the blood, making it the most relevant assessment for wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Primary Intention: Primary intention healing occurs when surgical incisions are closed with sutures, staples, or adhesive strips. Since laparoscopic procedures involve small incisions that are closed immediately, this type of healing applies.
B. Partial-thickness repair: Partial-thickness repair refers to wounds that involve only the epidermis and part of the dermis (e.g., abrasions, minor burns). Surgical incisions are full-thickness wounds, so this is not applicable.
C. Secondary Intention: Secondary intention healing occurs when wounds heal from the inside out, typically seen in pressure ulcers, large open wounds, or infected wounds. Surgical wounds that are sutured do not heal by secondary intention.
D. Tertiary Intention: Tertiary intention healing occurs when a wound is left open initially and later closed due to infection risk or delayed healing. Laparoscopic appendectomy wounds are closed immediately, making this choice incorrect.
Correct Answer is C
Explanation
A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.
B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.
C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.
D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.
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