Which assessment charting indicates that the wound is healing by primary intention?

A superficial 3-inch x 3-inch abrasion has no active bleeding, drainage, or debris.

The 4-inch incision edges are well approximated with intact sutures.

An ulcerated 3-inch x 1-inch area has thick yellow slough present in the center.

The incision is 5 inches long x 1 inch deep x 1 inch wide with granulation tissue present.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A superficial abrasion heals by secondary intention, not primary intention.

In secondary intention healing, the wound is left open to heal from the inside out. This type of healing is typically slower and results in more scar tissue formation.

The absence of active bleeding, drainage, or debris is a positive sign, but it does not guarantee that the wound is healing by primary intention.

Choice C rationale:

The presence of thick yellow slough indicates that the wound is infected and not healing properly. This is a sign of delayed healing, not primary intention healing.

Choice D rationale:

The presence of granulation tissue is a sign of healing, but it does not indicate whether the wound is healing by primary or secondary intention.

Granulation tissue is a type of new tissue that forms during the healing process. It is composed of blood vessels, collagen, and fibroblasts.

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Correct Answer is A

Explanation

Choice A rationale:

Hemorrhoids are swollen veins in the anus and rectum that can cause pain, itching, and bleeding. Sitz baths are a common and effective treatment for hemorrhoids because they can help to:

Reduce inflammation and pain Promote healing

Relax the anal sphincter muscles Cleanse the anal area

Warm water helps to increase blood flow to the area, which can help to reduce swelling and inflammation. The water also helps to soothe and cleanse the irritated tissues.

Sitz baths are typically taken for 10-15 minutes at a time, several times a day. They can be taken in a bathtub or a special sitz bath basin that fits over a toilet seat.

Choice B rationale:

A fractured right arm would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice C rationale:

An abscessed tooth would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice D rationale:

Painful back muscle spasms would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

A. Teach the patient to splint the incision when coughing to minimize pain. B. Assist the patient to sit up in the chair and ambulate in the hallway. C. Watch the patient use the incentive spirometer and ensure hourly usage. D. Dim the lights, provide warm blankets, and maintain a quiet environment. E. Maintain patient privacy and use therapeutic touch as desired by the patient.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue).

Steps for splinting the incision:

Place a pillow or folded towel over the incision site.

Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.

Choice B rationale:

Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up.

Additional benefits of sitting up and ambulating: Improved circulation

Decreased risk of pneumonia Enhanced recovery from surgery Choice C rationale:

Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs.

Instructions for using an incentive spirometer:

Sit upright in a chair or bed.

Place the mouthpiece of the spirometer in your mouth and seal your lips around it.

Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds.

Exhale slowly and completely through the mouthpiece.

Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.

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Which assessment charting indicates that the wound is healing by primary intention?

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Explanation

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