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 A

Explanation

Choice A rationale:

An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.

Choice B rationale:

A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.

Choice D rationale:

A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.

A. The patient has to be repositioned for the bed to be changed. B. Shearing is more likely from wet sheets. C. The moisture creates an environment suitable for the growth of microorganisms in a wound. D. Greater pressure is exerted by a wet bed.

Correct Answer is C

Explanation

Choice A rationale:

Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.

Choice B rationale:

While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.

Choice C rationale:

Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.

Choice D rationale:

A wet bed does not exert greater pressure on the patient’s skin.

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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:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

When applying an ice pack, it is necessary to:

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

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A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

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After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

Chronic wounds that are not healing well may benefit from (Select all that apply.)

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: