A nurse is assessing a client who has a wound that is healing by primary intention. Which of the following findings should the nurse expect?

Granulation tissue forming at the bottom of the wound bed.

Healing of the wound is prolonged.

Skin edges of the wound are sutured closed.

Wound is contaminated at the time of injury

Answer and Explanation

The Correct Answer is C

A) Granulation tissue forming at the bottom of the wound bed:
Granulation tissue typically forms in wounds that heal by secondary intention. This type of healing occurs when the wound edges are not approximated (e.g., a large or open wound), and new tissue must form to fill the gap. In primary intention healing, the wound edges are well approximated, and granulation tissue is not the hallmark of the healing process, although some may appear early on.

B) Healing of the wound is prolonged:
Wounds healing by primary intention generally heal more quickly than those healing by secondary intention. In primary intention, the wound edges are approximated with sutures, staples, or adhesive, allowing for a faster and more efficient healing process. Therefore, prolonged healing is not expected with primary intention]

C) Skin edges of the wound are sutured closed:
This is the correct finding for a wound healing by primary intention. Primary intention healing occurs when the wound edges are brought together (approximated) and secured with sutures, staples, or adhesive strips. This method promotes faster healing and minimal scarring because the tissue is directly aligned.

D) Wound is contaminated at the time of injury:
Wounds that heal by primary intention are generally clean and not contaminated. If a wound is contaminated or infected at the time of injury, it is more likely to heal by secondary intention, where the tissue must fill in from the base upwards, which takes longer and may result in more scarring.

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Correct Answer is D

Explanation

A) Place the client on a low-fiber diet:
A low-fiber diet is not recommended for patients experiencing constipation. Fiber plays a key role in bowel regularity by absorbing water and adding bulk to stool, which promotes movement through the intestines. In fact, a high-fiber diet (from fruits, vegetables, whole grains, and legumes) is usually recommended for clients with constipation. Reducing fiber intake can worsen constipation and should be avoided unless otherwise directed by a healthcare provider for specific conditions (e.g., during acute exacerbations of inflammatory bowel disease).

B) Request a prescription for a mineral oil for the client:
Mineral oil is a laxative that is sometimes used to relieve constipation, but it is typically used only for short-term relief and under specific circumstances. Long-term use of mineral oil can interfere with the absorption of fat-soluble vitamins (A, D, E, and K) and can also lead to a lipid pneumonia if aspirated. It is not the first-line intervention for a patient on bed rest with constipation and should not be used indiscriminately without a provider's recommendation.

C) Encourage the client to drink cold fluids:
While fluid intake is essential for managing constipation, it is not specifically the temperature of the fluid that makes a difference. Both cold and room temperature fluids are effective, but encouraging the client to increase fluid intake overall is the most important action. Water is particularly helpful, as it helps soften stool and aids in the movement through the colon.

D) Increase the client's fluid intake:
Increasing fluid intake is the most effective intervention for constipation, especially for a client on bed rest. Adequate hydration helps to soften stool and can promote more regular bowel movements. Inactive individuals, such as those on bed rest, are more prone to constipation because of decreased physical activity and potentially insufficient fluid intake.

Correct Answer is ["0.75"]

Explanation

Given:

Ordered dose of Enoxaparin: 30 mg

Concentration of Enoxaparin: 40 mg/mL

Step 1: Set up the proportion:

Desired dose (mg) / Volume to administer (mL) = Concentration (mg/mL)

Step 2: Substitute the values:

30 mg / Volume = 40 mg/mL

Step 3: Solve for the unknown volume:

Volume = 30 mg / (40 mg/mL)

Volume = 30 mg x (1 mL / 40 mg)

Volume = 0.75 mL

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A nurse is assessing a client who has a wound that is healing by primary intention. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

Correct Answer is D

Explanation

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.75"]

Explanation

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