A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
Shearing is more likely from wet sheets.
The patient has to be repositioned for the bed to be changed.
The Correct Answer is A
Choice A rationale
Moisture from incontinence can compromise skin integrity and create a favorable environment for bacterial growth, increasing the risk of infection and skin breakdown.
Choice B rationale
While a wet bed may be uncomfortable, it does not exert greater pressure that would lead to skin breakdown or infection.
Choice C rationale
Shearing can occur from moving a patient on any surface; however, wet sheets do not inherently increase the likelihood of shearing.
Choice D rationale
Repositioning the patient is necessary for comfort and to prevent pressure ulcers, but it is not a direct cause of skin breakdown or infection due to incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The remodeling phase is the final stage of the healing process, where the wound strength and function are gradually restored over time. This phase does not involve initial suturing; rather, it is the period after the wound has closed. Therefore, this choice does not pertain to the initial management of a wound with an active infection.
Choice B rationale
Healing by primary intention involves closing a wound with sutures, staples, or adhesive to facilitate healing. However, when there is an infection, suturing is delayed until the infection is resolved to prevent trapping bacteria inside, which could worsen the infection or lead to abscess formation. Once the infection is under control, the wound can be closed, promoting faster and more cosmetically appealing healing. This method reduces scarring and speeds recovery compared to secondary intention, where the wound is left open to heal from the bottom up.
Choice C rationale
Tertiary intention, also known as delayed primary closure, is used when there is a need to delay closing the wound, often due to infection. The wound is left open to allow for adequate drainage and resolution of the infection before it is sutured closed. This method helps to prevent the entrapment of bacteria within the wound, which could exacerbate the infection1.
Choice D rationale
Secondary intention healing occurs when a wound is left open and allowed to close on its own without surgical closure. This method is typically used for wounds with significant tissue loss or those that cannot be closed directly. It is not specifically related to the delay of suturing due to infection
Correct Answer is C
Explanation
Choice A rationale
Excessive gas is not typically an indication of wound dehiscence. While it may cause discomfort, it does not suggest that the wound layers have separated.
Choice B rationale
A complaint of constipation is a common postoperative concern due to decreased mobility and use of narcotics but is not a sign of wound dehiscence.
Choice C rationale
Increased drainage from the wound, especially if the fluid is clear or serous, can be an early sign of dehiscence, indicating that the wound layers are separating and fluid is accumulating.
Choice D rationale
Increased pallor of the surgical site might indicate poor perfusion but is not a direct sign of dehiscence. Dehiscence would more likely show signs of inflammation or unusual discharge.
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