A nurse is performing skin assessments for a group of clients. Which of the following images indicates a wound that is healing by secondary intention?
A: Circular Red Area
B: Bruise on Leg
C: Sutured Incision (Primary intention)
D: Open Ulcer/Pressure Injury (Secondary Intention)
The Correct Answer is D
Rationale:
A. Circular Red Area: This is a Stage 1 Pressure Injury (non-blanchable erythema or shallow ulcer).
B. Bruise on Leg: This shows contusion/bruising (ecchymosis) and possible swelling, which is a closed injury, not an open wound that requires healing by intention.
C. Sutured Incision (Primary intention): The wound edges are cleanly approximated (brought together) with sutures, staples, or adhesive. Minimal tissue loss occurred. Healing occurs rapidly, with minimal granulation tissue and minimal scarring. The image showing the clean, surgical incision closed with staples or sutures.
D. Open Ulcer/Pressure Injury (Secondary Intention): The wound has significant tissue loss, irregular borders, and the edges cannot be approximated (closed). The wound is left open to heal by granulation (formation of new connective tissue) from the bottom up. This process is slower and results in a larger, more noticeable scar.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale
A. Insulin Glargine 20 units SUBQ qd: The abbreviation "qd" can be misinterpreted and is considered unsafe in medication orders. Insulin requires precise dosing and timing to prevent hypo- or hyperglycemia. The nurse should clarify the prescription with the provider and document "once daily" to ensure safe administration.
B. Ceftriaxone 250 mg IM stat: This prescription is clear regarding the medication, dose, route, and timing. "Stat" indicates immediate administration, which is understandable and requires no clarification.
C. Diazepam 5 mg PO Q8h PRN muscle spasms: The prescription clearly specifies the dose, route, frequency, and indication. The nurse can safely administer as needed without needing clarification.
D. Digoxin 0.5 mg IV once: The prescription provides complete information about the medication, dose, route, and single administration. No ambiguous abbreviations are present, so clarification is unnecessary.
Correct Answer is B
Explanation
Rationale
A. "A client can be discharged to another facility if their behavior is unsafe and inappropriate.": EMTALA focuses on stabilizing medical emergencies, not on behavior-related issues. Discharging solely based on unsafe behavior would violate the client’s right to emergency care.
B. "A client can be discharged to another facility when their condition stabilizes.": EMTALA requires that clients presenting with an emergency medical condition must be evaluated and stabilized before discharge or transfer. This statement reflects proper understanding of the act’s requirement to ensure patient safety and continuity of care.
C. "A client can be discharged to another facility if they are unable to pay for services received.": EMTALA prohibits refusing care or transferring a patient based on inability to pay. Emergency treatment must be provided regardless of financial status, making this statement incorrect.
D. "A client can be discharged to another facility if their condition is terminal.": Terminal status alone does not justify discharge or transfer under EMTALA. The patient must still receive emergency stabilization or palliative support in compliance with legal and ethical requirements.
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