Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?
Hemostasis
Inflammatory phase
Maturation phase
Proliferation phase
The Correct Answer is D
Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale: The skin helps regulate body temperature by sweating and dilation or constriction of blood vessels.
Choice B rationale: The skin acts as a barrier, protecting the body from external threats such as pathogens and physical injury.
Choice C rationale: The skin is rich in sensory receptors, allowing for the perception of touch, pressure, pain, and temperature.
Choice D rationale: The skin plays a role in the production of vitamin D when exposed to sunlight.
Choice E rationale: Vitamin C production is not a function of the skin; vitamin C is obtained through diet.
Correct Answer is A
Explanation
Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.
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