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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is A
Explanation
A) Potassium level 3 mEq/L:
A potassium level of 3 mEq/L is below the normal range (which is typically 3.5-5.0 mEq/L) and represents hypokalemia. Potassium is crucial for normal muscle and nerve function, including cardiac function. Low potassium levels can lead to dangerous arrhythmias, muscle weakness, and cardiac arrest if not addressed promptly. This is the priority value because hypokalemia can be life-threatening and requires immediate attention from the healthcare provider to correct the imbalance.
B) BUN 9.5 mg/dl:
A BUN (blood urea nitrogen) level of 9.5 mg/dL is within the normal reference range for most adults (typically 7-20 mg/dL). While an abnormal BUN level could indicate kidney dysfunction or dehydration, this value is not immediately concerning and does not represent a critical finding that requires urgent attention.
C) Creatinine 0.4 mg/dl:
A creatinine level of 0.4 mg/dL is below the normal range (usually around 0.6-1.2 mg/dL), which might indicate low muscle mass or a transient decrease in kidney function. However, a low creatinine level is generally not as urgent or concerning as an elevated level, and it does not typically require immediate intervention
D) Sodium 135 mEq/L:
A sodium level of 135 mEq/L is slightly below the normal range (135-145 mEq/L), indicating mild hyponatremia. Although this can be concerning if the drop is acute or symptomatic (e.g., causing confusion, seizures, or lethargy), a mild decrease in sodium is not immediately life-threatening unless it worsens rapidly.
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