Many factors aid in healing. You can assist the patient in improving their healing ability by encouraging the following (Select all that apply):
Keeping skin and surrounding tissue clean and dry.
Proper nutrition with adequate protein and vitamins.
Resting as much as possible and keeping the incisional area still.
Increasing fluid intake to at least 4000 mL per day.
Exercise and deep breathing to increase oxygen.
Correct Answer : A,B,C,E
Choice A rationale
Keeping the skin and surrounding tissue clean and dry helps prevent infection, which is crucial for proper wound healing. A clean environment is less likely to harbor bacteria that can cause complications.
Choice B rationale
Proper nutrition, particularly adequate protein and vitamins, provides the necessary building blocks for tissue repair and supports the immune system, which is essential for healing.
Choice C rationale
Resting and minimizing movement of the incisional area help prevent further injury and allow the body’s resources to focus on the healing process.
Choice D rationale
While fluid intake is important, 4000 mL per day may be excessive unless specifically recommended for the patient’s condition. Overhydration can be harmful.
Choice E rationale
Exercise and deep breathing increase blood flow and oxygenation to tissues, which are vital for healing. Oxygen is needed for cellular functions that repair tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Excessive gas is not typically an indication of wound dehiscence. While it may cause discomfort, it does not suggest that the wound layers have separated.
Choice B rationale
A complaint of constipation is a common postoperative concern due to decreased mobility and use of narcotics but is not a sign of wound dehiscence.
Choice C rationale
Increased drainage from the wound, especially if the fluid is clear or serous, can be an early sign of dehiscence, indicating that the wound layers are separating and fluid is accumulating.
Choice D rationale
Increased pallor of the surgical site might indicate poor perfusion but is not a direct sign of dehiscence. Dehiscence would more likely show signs of inflammation or unusual discharge.
Correct Answer is B
Explanation
Choice A rationale
A contusion, commonly known as a bruise, is characterized by bleeding under the skin, causing discoloration and swelling. It does not involve a break in the skin and therefore does not match the description of the wound with torn skin tissue.
Choice B rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse discovered torn skin tissue, this type of wound is consistent with the client’s injury described in the scenario.
Choice C rationale
An abrasion is a wound caused by superficial damage to the skin, usually no deeper than the epidermis. It is typically caused by a scrape against a rough surface and is not associated with torn skin tissue.
Choice D rationale
A puncture is a small hole caused by a long, pointed object, such as a nail or needle. This type of wound usually does not result in torn skin tissue but rather a deeper, more narrow penetration.
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