A nurse is collecting data on a client who has a wound that is healing by first 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.
Wound is contaminated at the time of injury.
Skin edges of the wound are sutured closed with edges that are well approximated.
The Correct Answer is D
A. Granulation tissue forming at the bottom of the wound bed:
Granulation tissue is associated with second intention healing, where the wound is open and heals from the base up.
B. Healing of the wound is prolonged:
First intention healing is typically faster and involves minimal tissue loss.
C. Wound is contaminated at the time of injury:
First intention healing usually involves clean, surgical wounds, not contaminated wounds.
D. Skin edges of the wound are sutured closed with edges that are well approximated:
This is characteristic of primary intention healing, where surgical or clean wounds are closed with sutures or staples.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.
B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.
C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.
D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.
Correct Answer is A
Explanation
A. Choose a finger with a capillary refill less than 2 sec:
This ensures adequate peripheral perfusion, which is necessary for accurate pulse oximetry.
B. Obtain the oxygen saturation reading immediately after applying the sensor probe:
Wait a few seconds for the sensor to stabilize and detect accurate values.
C. Place the sensor probe on the same extremity as an electronic BP cuff:
A BP cuff can interfere with readings by restricting blood flow.
D. Relocate the sensor every 8 hrs:
Sensors should be relocated every 2–4 hours to prevent skin breakdown, especially in continuous monitoring.
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