A nurse is assessing a patient who has a wound that is healing by first intention. What findings should the nurse expect?
Granulation tissue forming at the bottom of the wound bed.
Wound was contaminated at the time of injury.
Healing of the wound is prolonged.
Skin edges of the wound are sutured closed.
The Correct Answer is D
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Purulent drainage is thick and opaque. It can have a yellow, tan, green, or brown color and is a sign of infection.
Choice B rationale
Sanguineous drainage is bright red and indicates active bleeding3.
Choice C rationale
Serosanguineous drainage is typically pink-red and thin. It is made up of blood and serous fluid and is typically seen in a normal, non-infected wound3.
Choice D rationale
Serous drainage is clear and thin, like the fluid from a blister3.
Correct Answer is A
Explanation
Choice A rationale
The nurse should plan to refrigerate the urine during the collection time period. This is because the urine needs to be kept cool to prevent the breakdown of certain analytes that might be measured in the urine.
Choice B rationale
The nurse should not discard the client’s last void at the end of the collection time period. The last voided specimen should be included in the collection to ensure that the 24-hour collection is complete.
Choice C rationale
The nurse should not include toilet paper with the collected urine. Toilet paper could contaminate the urine sample and interfere with the accuracy of the test results.
Choice D rationale
The nurse should not save the first void at the start of the collection time period. The first voided specimen should be discarded, and the collection should start with the next void.
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