The nurse is performing an initial wound assessment on a client's pressure injury and notes severe tissue destruction inhibiting the wound edges to approximate. Which wound healing technique will likely be used?
Quadrant intention.
Tertiary intention.
Secondary intention.
Primary intention.
The Correct Answer is C
A. Quadrant intention is not a recognized wound healing classification and is therefore incorrect. This term does not apply to standard surgical or pressure injury wound management.
B. Tertiary intention, also called delayed primary closure, involves initially leaving a wound open and later surgically closing it after infection risk is reduced. While this method is used in certain contaminated or high-risk surgical wounds, it is less commonly applied for pressure injuries with severe tissue loss. Tertiary intention may be used in select cases, but it is not the primary approach for pressure injuries where edges cannot approximate.
C. Secondary intention is correct. In secondary intention, the wound is allowed to heal naturally from the base upward, without surgical closure, because the edges cannot be approximated due to extensive tissue loss or destruction. This approach is typical for pressure injuries, large burns, or chronic wounds. Healing occurs through granulation tissue formation, contraction, and epithelialization, which accommodates irregular wound beds and extensive tissue loss.
D. Primary intention is incorrect. Primary intention involves directly approximating wound edges with sutures, staples, or adhesive, resulting in faster healing with minimal scarring. This technique is suitable for clean, surgical wounds with minimal tissue loss. In the scenario described, the wound edges cannot approximate, making primary intention inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["E","F"]
Explanation
A. Urinalysis is not typically used to evaluate the effectiveness of an antibiotic for a respiratory tract infection. While urinalysis can detect urinary tract infections or kidney abnormalities, it does not provide information about the resolution of a respiratory infection.
B. Blood urea nitrogen (BUN) is primarily monitored to assess kidney function, especially for nephrotoxic antibiotics such as aminoglycosides. While important for safety monitoring, BUN does not indicate whether the respiratory infection is improving.
C. Serum potassium is relevant for monitoring potential electrolyte imbalances that may occur with certain medications or illness, but it does not provide information about the effectiveness of an antibiotic in treating a respiratory infection.
D. Red blood cell count is not affected by the administration of antibiotics for acute respiratory infections and does not reflect infection resolution. Monitoring RBC count is unrelated to evaluating antibiotic efficacy.
E. White blood cell count is correct. WBC count is a marker of infection and inflammation. A decrease in elevated WBCs toward normal levels indicates that the infection is responding to antibiotic therapy. Monitoring trends in WBC count helps the nurse evaluate whether the medication is effective in reducing the body’s inflammatory response.
F. Sputum culture and sensitivity is correct. Obtaining a sputum culture identifies the causative pathogen and determines which antibiotics are effective against it. Follow-up cultures can show whether the infection has been eradicated, providing a direct measure of the antibiotic’s effectiveness.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
- Involve parents in procedure if desired (Infant): Infants rely on their parents for security and comfort; having parents present helps develop trust and reduces anxiety.
- Designate one HCP to speak during procedure (Toddler): Toddlers benefit from clear, consistent communication; having one person give instructions helps reduce confusion and fosters trust.
- Keep parents in line of vision (Infant): Seeing a familiar caregiver provides reassurance and emotional support for infants during procedures.
- Place familiar object with client if parents cannot be there (Infant): Comfort items such as a blanket or toy help soothe infants and maintain a sense of security.
- Prepare parents separately to avoid misinterpretation of words (Toddler): Toddlers can misinterpret explanations; preparing parents ensures they can support and accurately communicate with the child.
- Use firm and direct approach (Toddler): Toddlers respond best to simple, direct instructions and boundaries to feel safe during procedures.
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