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 C

Explanation

Choice A rationale:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

A. Leave it until the end of the shift. B. Remove the drain. C. Empty the reservoir. D. Notify the surgeon about the blood loss.

Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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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

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 a:

Correct Answer is C

Explanation

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

Correct Answer is C

Explanation

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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: