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.

Answer and Explanation

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.

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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.

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Correct Answer is A

Explanation

Choice A rationale
A Stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The presence of pain and redness that does not blanch when pressure is applied are indicative of this early stage of pressure injury.

Choice B rationale
Stage 2 pressure injuries involve partial-thickness loss of dermis and present as a shallow open ulcer with a red-pink wound bed, without slough. This does not match the description of the patient’s condition, which indicates intact skin.

Choice C rationale
Stage 3 pressure injuries are defined by full-thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s symptoms do not suggest such an advanced stage.

Choice D rationale
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Since the patient’s skin is intact and only red, this stage does not apply.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Correct Answer is B

Explanation

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip. He states that it is painful. This is indicative of which stage of pressure injury?

Correct Answer is A

Explanation

When preparing to change a sterile dressing over an incision, it is most important to remember to:

What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?

A nurse performing a right eye irrigation will position the patient in which of the following ways?

The nurse clarifies that a vacuum-assisted closure supports the healing of a wound by:

A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:

After closing the curtain around the client’s bed and lifting his gown to expose the horizontal abdominal wound, which of the following positions should you assist the client into for comfortable wound irrigation?

What type of wound heals by edges approximating with a suture?

The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?