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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Reposition the client every 3 hr:
At-risk clients should be repositioned at least every 2 hours, not every 3, to relieve pressure and promote circulation.

B. Provide the client with a diet high in protein:
Protein is essential for maintaining skin integrity and promoting tissue repair and healing.

C. Apply cornstarch to keep the skin dry:
Cornstarch can cause skin irritation and increase the risk of skin breakdown and infection in moist environments.

D. Massage bony prominences to promote circulation:
Massaging bony prominences can damage fragile tissues and increase the risk of pressure injuries.

A. Restricting fluid intake B. Using a pillow to support the abdomen when coughing C. Encouraging early ambulation D. Administering high-dose corticosteroids

Correct Answer is B

Explanation

A. Restricting fluid intake:
Adequate hydration is important for wound healing. Restricting fluids does not prevent dehiscence and may hinder recovery.

B. Using a pillow to support the abdomen when coughing:
This is called splinting the incision. It reduces stress on the wound during coughing or movement, helping prevent dehiscence.

C. Encouraging early ambulation:
Early ambulation promotes recovery and prevents complications like DVT or pneumonia, but does not directly prevent wound dehiscence.

D. Administering high-dose corticosteroids:
Corticosteroids impair wound healing and increase the risk of dehiscence. They are not preventative.

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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?

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