The new nurse reads a client has a wound "healing by second intention" and ask what that means. Which description by the charge nurse is most accurate?

"The wound was stapled together after an infection was cleared up".

"The wound is an open cavity that will fill in with granulation tissue."

"The wound edges have been approximated and stitched together."

"The wound was contaminated by debris and can't be closed at all."

Answer and Explanation

The Correct Answer is B

A. "The wound was stapled together after an infection was cleared up": This describes primary intention healing, where wound edges are surgically approximated after cleaning or debridement. Stapling or suturing is not part of second-intention healing.

B. "The wound is an open cavity that will fill in with granulation tissue": Second-intention healing occurs when a wound is left open due to tissue loss, contamination, or infection risk. The wound gradually fills with granulation tissue, contracts, and epithelializes over time. This process allows natural healing without suturing.

C. "The wound edges have been approximated and stitched together": This describes primary intention healing, not second intention. Suturing or closing the wound edges accelerates healing but does not involve open wound granulation, so this description is inaccurate.

D. "The wound was contaminated by debris and can't be closed at all": While second-intention wounds may involve contamination or tissue loss, they are capable of healing naturally through granulation and epithelialization. The statement implies the wound cannot heal, which is incorrect; second-intention wounds do heal, albeit more slowly and with a higher risk of scarring.

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Correct Answer is B

Explanation

A. The client has been sleeping most of the day: Magnesium sulfate has a central nervous system depressant effect, so drowsiness and increased sleepiness are expected therapeutic effects. It reduces neuromuscular excitability and helps prevent seizures in eclampsia. Mild sedation alone is not an immediate sign of toxicity.

B. The client's respiratory rate is 6: A respiratory rate of 6 breaths/min indicates severe respiratory depression, which is a critical sign of magnesium toxicity. Magnesium inhibits neuromuscular transmission and can suppress the respiratory center in the brainstem. Respiratory depression can rapidly progress to respiratory arrest, making this a life-threatening emergency.

C. The patellar and triceps reflexes are decreased: Diminished deep tendon reflexes are an early sign of magnesium sulfate effect and can precede toxicity. However, slightly decreased reflexes may be expected at therapeutic levels. Complete absence of reflexes would be more concerning, but decreased reflexes alone are not as immediately life-threatening.

D. The client reports feeling "sick to my stomach": Nausea is a common side effect of magnesium sulfate and may occur due to its systemic effects on smooth muscle and the gastrointestinal tract. While it should be monitored and managed for comfort, it is not an indicator of severe toxicity requiring urgent intervention.

A. Transfer the client to the Intensive Care Unit. B. Continue monitoring every 30 minutes. C. Notify the unit charge nurse immediately. D. Call the Rapid Response Team.

Correct Answer is D

Explanation

A. Transfer the client to the Intensive Care Unit.: While ICU transfer may eventually be necessary for a deteriorating patient, the decision requires rapid bedside assessment and stabilization first. Immediate action is required before transfer decisions can safely be made.

B. Continue monitoring every 30 minutes.: The client exhibits signs of hemodynamic instability, including hypotension (BP 92/78 mmHg), tachycardia (136 bpm), bradypnea (RR 10/min), fever, and altered mental status (responds to voice). Waiting and monitoring without intervention risks further deterioration and delayed treatment.

C. Notify the unit charge nurse immediately.: Informing the charge nurse is appropriate, but rapid escalation to a team trained to manage acute patient deterioration is more urgent. Delays may compromise patient safety in a time-sensitive situation.

D. Call the Rapid Response Team.: The client meets multiple criteria for acute clinical deterioration, including hypotension, tachycardia, altered mental status, fever, and respiratory compromise. Activating the Rapid Response Team ensures immediate expert assessment and intervention to stabilize the patient, address potential sepsis, and prevent progression to shock or cardiac arrest.

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The new nurse reads a client has a wound "healing by second intention" and ask what that means. Which description by the charge nurse is most accurate?

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Naxlex Comprehensive Predictor Exams

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