The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.
The nurse further assesses that the wound is healing by:

Third intention.

First intention.

Second intention.

Fourth intention.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.

Choice B rationale:

First intention healing occurs when the wound edges are approximated, such as with sutures.

Choice C rationale:

Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.

Choice D rationale:

Fourth intention healing is not a recognized term in wound healing.

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Correct Answer is D

Explanation

Choice A rationale:

Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.

Choice B rationale:

Repositioning should be done every 2 hours or less for at-risk patients.

Choice C rationale:

Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.

Choice D rationale:

A high-calorie diet can promote skin integrity and wound healing.

A. BMI of 20. B. Peripheral neuropathy. C. Immobility. D. Hypoperfusion. E. Prealbumin level of 16 mg/dL.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.

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The nurse is taking care of a postsurgical 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 is at risk for a pressure injury.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

The nurse places Dakin solution in a wound to accomplish chemical:

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

A nurse is collecting data on a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

Enter instructional text.The nurse clarifies that the second stage of wound healing is:

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.
The nurse further assesses that the wound is healing by: