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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale: Stool expelled into an ileostomy bag is often of liquid consistency. An ileostomy involves the diversion of the small intestine, where the stool is more liquid compared to a colostomy, which involves the large intestine and typically produces more formed stool.
Choice B rationale: Bloody stool is not a typical characteristic of stool from an ileostomy.
Choice C rationale: Mucus-filled stool is not the primary characteristic of stool from an ileostomy.
Choice D rationale: Soft semi-formed stool is not typical of an ileostomy; the stool is more liquid in consistency.

A. Perform hand hygiene. B. Assess the condition of the visible wound bed. C. Measure the width of the wound with a disposable ruler. D. Insert a swab into the wound at 90 degrees.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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