The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

Primary Intention

Partial-thickness repair

Secondary Intention

Tertiary intention

Answer and Explanation

The Correct Answer is A

A. Primary Intention: Primary intention healing occurs when surgical incisions are closed with sutures, staples, or adhesive strips. Since laparoscopic procedures involve small incisions that are closed immediately, this type of healing applies.

B. Partial-thickness repair: Partial-thickness repair refers to wounds that involve only the epidermis and part of the dermis (e.g., abrasions, minor burns). Surgical incisions are full-thickness wounds, so this is not applicable.

C. Secondary Intention: Secondary intention healing occurs when wounds heal from the inside out, typically seen in pressure ulcers, large open wounds, or infected wounds. Surgical wounds that are sutured do not heal by secondary intention.

D. Tertiary Intention: Tertiary intention healing occurs when a wound is left open initially and later closed due to infection risk or delayed healing. Laparoscopic appendectomy wounds are closed immediately, making this choice incorrect.

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Correct Answer is D

Explanation

A. Hold her breath for at least 10 seconds. Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort.

B. Place her hands on the sides of her rib cage. While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding.

C. Exhale forcefully through the nose. Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.

D. Inhale slowly and evenly through her nose. The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively.

A. Making a clinical decision in the patient's best interest. B. Making a clinical decision based on previous shift assessments. C. Making an ethical clinical decision D. Making an informed clinical decision

Correct Answer is B

Explanation

A. Making a clinical decision in the patient's best interest: Making decisions in the patient’s best interest is an essential part of nursing practice and demonstrates good clinical judgment.

B. Making a clinical decision based on previous shift assessments. Nursing assessments should be conducted for each shift, as a patient’s condition can change rapidly. Relying on previous assessments without reassessing can lead to missed changes in the patient’s status, potentially causing harm.

C. Making an ethical clinical decision. Ethical decision-making is an integral part of nursing practice and aligns with professional standards. There is no need for intervention if the decision is ethical.

D. Making an informed clinical decision. Informed clinical decision-making is based on current patient data, clinical guidelines, and critical thinking. This is a correct approach to nursing care and does not require intervention.

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The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Correct Answer is D

Explanation

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Correct Answer is B

Explanation

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