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 B
Explanation
A. Partial-thickness skin loss with red tissue in wound bed:
This describes a stage 2 pressure injury, not stage 1.
B. Intact skin with localized erythema:
Stage 1 pressure injuries are characterized by non-blanchable redness (erythema) over intact skin.
C. Full thickness skin loss with visible adipose tissue:
This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone:
This describes a stage 4 pressure injury.
Correct Answer is C
Explanation
A. Palpate the client’s pulse at the third intercostal space:
The apical pulse is at the fifth intercostal space, midclavicular line-not the third. The third is not standard for pulse assessment.
B. Ask the client to perform the Valsalva maneuver:
This can be used in arrhythmias like supraventricular tachycardia but is not appropriate for assessment of irregular rhythm.
C. Auscultate the client’s apical pulse:
This is the most accurate way to assess an irregular pulse, especially for one full minute.
D. Check the client’s heart rate for 30 sec:
When a rhythm is irregular, you must assess for a full minute, not 30 seconds.
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