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 ["125"]
Explanation
Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.
Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.
Correct Answer is C
Explanation
Choice A rationale
While a patient’s medication history can impact wound healing, in this case, there is no specific information provided about the patient’s medications that would suggest a delay in wound healing.
Choice B rationale
Although the patient’s cholesterol level is elevated, hyperlipidemia is not typically associated with delayed wound healing.
Choice C rationale
Prealbumin is a marker of nutritional status. A low prealbumin level, like in this patient, could indicate malnutrition, which can delay wound healing. Adequate nutrition is essential for wound healing as it provides the necessary building blocks for tissue repair.
Choice D rationale
The patient’s fasting glucose level is within the normal range, so it is unlikely to impact wound healing. While poorly controlled diabetes can delay wound healing, this patient’s diabetes appears to be well-controlled.
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