A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?
Skin edges of the wound are sutured closed.
Wound is contaminated at the time of injury.
Granulation tissue forming at the bottom of the wound bed.
Healing of the wound is prolonged.
The Correct Answer is A
Choice A rationale: Wound healing by first intention involves the approximation of wound edges, often closed with sutures or staples, resulting in minimal scar formation.
Choice B rationale: Contamination at the time of injury is not characteristic of wounds healing by first intention.
Choice C rationale: Granulation tissue forming at the bottom of the wound bed is characteristic of wounds healing by second intention, not first intention.
Choice D rationale: Healing of the wound is typically quicker and involves less scarring in wounds healing by first intention compared to second intention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.
Correct Answer is D
Explanation
Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.
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