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 D
Explanation
Choice A rationale
Discarding the dressing in the bedside trash receptacle is not recommended because it can lead to the spread of infection. The dressing is contaminated with blood and purulent drainage, which are considered biohazardous waste.
Choice B rationale
Double-bagging the dressing in clear bags and labeling it “biohazard” is not sufficient. While it’s important to label biohazardous waste, the dressing should be disposed of in a designated biohazardous waste container.
Choice C rationale
Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is also not recommended. This method does not provide adequate containment for biohazardous waste.
Choice D rationale
Disposing of the dressing in a biohazardous waste container is the correct method. This ensures that the biohazardous waste is properly contained and reduces the risk of spreading infection.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.
Choice B rationale
Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.
Choice C rationale
Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.
Choice D rationale
Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.
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