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 A
Explanation
A. Use a cuff of the appropriate size for the client:
Using a cuff that is too small or too large can cause inaccurate readings. Proper sizing is crucial.
B. Assist the client to the bathroom to void:
While a full bladder can slightly affect BP, this is not the most essential step to ensure an accurate reading.
C. Apply the cuff loosely around the client’s arm:
A loose cuff will cause an inaccurate (falsely high) reading.
D. Obtain the reading in the early morning:
While BP naturally varies, the time of day is not critical to accurate technique unless part of a specific assessment schedule.
Correct Answer is B
Explanation
A. Use a cotton-tipped applicator to remove cerumen:
Inserting objects like cotton-tipped swabs into the ear canal is unsafe and can cause damage; not recommended for clearing earwax before temperature measurement.
B. Insert the probe snugly into the ear canal and press scan:
This is the correct method to ensure an accurate tympanic temperature reading.
C. Pull the pinna downward and backward:
This is correct for children under 3 years, not for adults.
D. Hold the probe flat against the forehead and press scan:
This technique is for a temporal artery thermometer, not tympanic.
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