The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:
Second intention.
Fourth intention.
Third intention.
First intention.
The Correct Answer is D
Choice A rationale
Healing by second intention occurs when a wound is left open and allowed to close by granulation, epithelialization, and contraction. This method is used for wounds that are infected, have lost tissue, or where there is a delay in suturing. It is not applicable in this case as the wound is sutured and healing cleanly.
Choice B rationale
There is no recognized method of wound healing known as fourth intention. This option does not exist in medical terminology related to wound healing and is therefore not a correct choice.
Choice C rationale
Third intention, also known as delayed primary closure, is when a wound is initially left open due to contamination or infection and is not closed until it is clean. This is not the case here as the wound has been sutured closed from the beginning.
Choice D rationale
First intention, also known as primary intention, is when a clean wound is immediately closed with sutures, staples, or adhesive, leading to minimal scarring. This is the method described in the scenario, where the post-surgical wound is clean, dry, and the sutures are intact, indicating healing by first intention. This method is typically used for surgical incisions under sterile conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Tegaderm or Opsite dressings are transparent and adhesive, allowing for wound inspection without removal, but they do not involve tape that remains in place for multiple changes.
Choice B rationale
Abdominal pads held in place with paper tape would require the tape to be removed and replaced with each dressing change, which can disrupt the skin.
Choice C rationale
The term ‘retention’ is incomplete and does not specify a type of dressing. Retention typically refers to the ability to keep something in place, such as a dressing, but does not imply that the tape remains in place.
Choice D rationale
Montgomery straps are designed with ties that attach to an adhesive base that remains on the skin. This allows the dressing to be changed without removing and reapplying tape, thus preventing skin disruption.
Correct Answer is B
Explanation
Choice A rationale
Applying hydrocolloids to the wound bed is not a form of mechanical debridement. Hydrocolloids are dressings that provide a moist environment and promote autolytic debridement but do not mechanically remove necrotic tissue.
Choice B rationale
Pulsating lavage is a form of mechanical debridement. It involves the use of a pressurized, pulsed solution to cleanse and remove debris and necrotic tissue from the wound bed, which is essential for the healing process of a stage 4 pressure injury.
Choice C rationale
Using a topical enzyme solution in the wound bed is a chemical, not mechanical, method of debridement. Enzymatic debridement uses proteolytic enzymes to break down necrotic tissue without affecting viable tissue.
Choice D rationale
Placing a transparent dressing over the pressure injury is not a form of debridement. Transparent dressings allow for oxygen exchange and protect the wound from infection, but they do not debride the wound.
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