The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.
The nurse further assesses that the wound is healing by:

Third intention.

First intention.

Second intention.

Fourth intention.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.

Choice B rationale:

First intention healing occurs when the wound edges are approximated, such as with sutures.

Choice C rationale:

Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.

Choice D rationale:

Fourth intention healing is not a recognized term in wound healing.

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Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

A. Irrigate the wound until the solution that is draining is clear. B. Chill the irrigant prior to the procedure. C. Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating. D. Flush the wound from the most contaminated area to the cleanest area.

Correct Answer is A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

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The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

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Explanation

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Correct Answer is A

Explanation

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The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.
The nurse further assesses that the wound is healing by: