Which assessment charting indicates that the wound is healing by primary intention?
A superficial 3-inch x 3-inch abrasion has no active bleeding, drainage, or debris.
The 4-inch incision edges are well approximated with intact sutures.
An ulcerated 3-inch x 1-inch area has thick yellow slough present in the center.
The incision is 5 inches long x 1 inch deep x 1 inch wide with granulation tissue present.
The Correct Answer is B
Choice A rationale:
A superficial abrasion heals by secondary intention, not primary intention.
In secondary intention healing, the wound is left open to heal from the inside out. This type of healing is typically slower and results in more scar tissue formation.
The absence of active bleeding, drainage, or debris is a positive sign, but it does not guarantee that the wound is healing by primary intention.
Choice C rationale:
The presence of thick yellow slough indicates that the wound is infected and not healing properly. This is a sign of delayed healing, not primary intention healing.
Choice D rationale:
The presence of granulation tissue is a sign of healing, but it does not indicate whether the wound is healing by primary or secondary intention.
Granulation tissue is a type of new tissue that forms during the healing process. It is composed of blood vessels, collagen, and fibroblasts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Directly addresses the primary goal of preventing perioperative positioning injury: The absence of redness or breakdown in the skin is the most definitive indicator that the patient has not sustained any skin or tissue damage as a result of prolonged immobilization during surgery.
Focuses on the patient outcome, not just interventions: While interventions such as padding bony prominences and assessing skin prior to surgery are important, they are means to achieve the ultimate goal of preventing skin injury. This outcome statement directly measures the success of those interventions.
Aligns with best practices for pressure injury prevention: The National Pressure Injury Advisory Panel (NPIAP) and other expert organizations emphasize the importance of setting goals that focus on maintaining skin integrity and preventing injury.
Choice B rationale:
Addresses a crucial aspect of patient care, but not directly related to positioning injury: Maintaining privacy and dignity is essential for all patients, but it does not specifically address the risk of skin breakdown from prolonged immobilization.
Not a measurable outcome for positioning injury: It is difficult to objectively assess whether a patient's privacy and dignity have been maintained, making it less suitable as an outcome statement for this particular diagnosis.
Choice C rationale:
Describes an important intervention, but not a patient outcome: Padding bony prominences is a key strategy to reduce pressure and prevent skin injury. However, it is an action taken by the nurse, not a measurable outcome that reflects the patient's status.
Does not guarantee prevention of injury: Even with appropriate padding, patients can still develop pressure injuries if other risk factors are present or if repositioning is not performed adequately.
Choice D rationale:
Represents an essential assessment step, but not a final outcome: Assessing the skin prior to surgery is important for identifying areas that are at increased risk of breakdown. However, it is a preliminary step in the prevention process, not the ultimate goal.
Does not ensure prevention of injury: Identifying at-risk areas is helpful for targeting interventions, but it does not guarantee that skin breakdown will not occur.
Correct Answer is A
Explanation
Choice A rationale:
Hemorrhoids are swollen veins in the anus and rectum that can cause pain, itching, and bleeding. Sitz baths are a common and effective treatment for hemorrhoids because they can help to:
Reduce inflammation and pain Promote healing
Relax the anal sphincter muscles Cleanse the anal area
Warm water helps to increase blood flow to the area, which can help to reduce swelling and inflammation. The water also helps to soothe and cleanse the irritated tissues.
Sitz baths are typically taken for 10-15 minutes at a time, several times a day. They can be taken in a bathtub or a special sitz bath basin that fits over a toilet seat.
Choice B rationale:
A fractured right arm would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.
Choice C rationale:
An abscessed tooth would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.
Choice D rationale:
Painful back muscle spasms would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.
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