The nurse is caring for a client with a surgically debrided wound, which the surgeon has left open to drain and will delay closure for the time being. The nurse understands that this type of intention is known as?

surgical intention

secondary intention

primary intention

tertiary intention

Answer and Explanation

The Correct Answer is D

A. Surgical intention: This is a nonspecific term that does not correspond to standard classifications of wound healing. While all surgical wounds involve some type of healing intention, this term is not used to describe the method of closure or healing process.

B. Secondary intention: Wounds healing by secondary intention are left open because of tissue loss or infection and heal naturally through granulation, contraction, and epithelialization. While similar, secondary intention is usually for chronic or non-surgical wounds, not for delayed closure of a surgically debrided wound.

C. Primary intention: Primary intention occurs when wound edges are approximated and closed immediately with sutures, staples, or adhesive, resulting in minimal scarring. This is typical for clean surgical incisions but does not apply when the wound is intentionally left open to drain.

D. Tertiary intention: Also called delayed primary closure, tertiary intention involves leaving a surgically created wound open temporarily to allow for drainage, reduce infection risk, and promote healthy granulation tissue formation. Closure is performed later when the risk of infection is reduced, making this the correct classification for a surgically debrided, open wound awaiting delayed closure.

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Correct Answer is A

Explanation

A. Partial-thickness skin loss involving epidermis and/or dermis: Stage II pressure injuries are characterized by partial-thickness loss of skin, affecting the epidermis and possibly the superficial dermis. The wound may present as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured blister. The underlying tissue is still protected, and there is no exposure of deeper structures such as muscle, tendon, or bone.

B. Full-thickness skin loss exposing muscle or bone: This finding corresponds to Stage III or Stage IV pressure injuries. Stage III involves full-thickness skin loss with damage or necrosis of subcutaneous tissue, whereas Stage IV extends to muscle, bone, or supporting structures. Stage II wounds do not involve these deeper layers.

C. Eschar obscuring the wound bed: Eschar is necrotic tissue that can cover Stage III or IV pressure injuries, often appearing black, brown, or tan. In Stage II pressure injuries, the wound bed is typically viable and pink, without necrotic tissue obscuring visualization.

D. Intact skin with non-blanchable erythema: This is indicative of a Stage I pressure injury, where the skin remains intact but shows persistent redness or discoloration that does not blanch when pressure is applied. Stage II involves partial-thickness skin loss, which distinguishes it from Stage I.

A. Anxious client awaiting a procedure reporting new onset of chest pressure B. Angry client dissatisfied with the room and demands to speak to the unit director C. Status post surgical client complaining of pain 4/10 at a large incision site D. Client admitted with a bowel obstruction who has nausea and vomiting

Correct Answer is A

Explanation

A. Anxious client awaiting a procedure reporting new onset of chest pressure: New chest pressure in a client can indicate acute myocardial ischemia or another life-threatening cardiac event. Immediate assessment and intervention are critical to ensure patient safety, making this the highest-priority client. Prompt recognition of potential cardiac compromise is essential to prevent deterioration.

B. Angry client dissatisfied with the room and demands to speak to the unit director: While addressing patient concerns and complaints is important for patient satisfaction and communication, this situation is non-urgent and does not pose an immediate threat to the client’s physiological stability.

C. Status post-surgical client complaining of pain 4/10 at a large incision site: Moderate pain requires timely management to promote comfort and recovery; however, it does not indicate an immediate life-threatening condition. Pain management is important but secondary to acute chest pain.

D. Client admitted with a bowel obstruction who has nausea and vomiting: Nausea and vomiting need assessment and intervention to prevent complications such as dehydration, but unless accompanied by signs of hemodynamic instability or electrolyte imbalance, this is less urgent than acute chest pain signaling potential cardiac compromise.

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The nurse is caring for a client with a surgically debrided wound, which the surgeon has left open to drain and will delay closure for the time being. The nurse understands that this type of intention is known as?

Nursing Test Bank

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