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 D
Explanation
Rationale for Choice A:
While maintaining normal body temperature is important for overall health, it's not the most immediate priority in a patient with fluid volume deficit due to ongoing bleeding. Fluid volume status takes precedence over temperature regulation in this context.
Hypovolemia can lead to hypothermia, but addressing the fluid deficit directly will also help stabilize temperature.
Focusing solely on temperature could delay crucial interventions to address the fluid loss and potentially worsen the patient's condition.
Rationale for Choice B:
An intact surgical incision is essential for proper wound healing and prevention of infection. However, in the context of active bleeding, it's not the priority outcome.
Maintaining adequate fluid volume is crucial to ensure perfusion of tissues, delivery of oxygen and nutrients, and proper organ function—all of which take precedence over incision integrity in this acute situation.
Addressing the fluid deficit will indirectly support wound healing by promoting tissue perfusion and reducing the risk of complications.
Rationale for Choice C:
Patient education is important, but it's not the most immediate priority in a patient with active bleeding and fluid volume deficit.
The patient's ability to comprehend and implement measures to reduce fluid loss may be compromised due to the hypovolemic state and potential cognitive effects.
Focusing on patient education at this stage could delay essential interventions to address the fluid loss and potentially worsen the patient's condition.
Rationale for Choice D:
Urine output is a sensitive and reliable indicator of renal perfusion and overall fluid status. In a patient with fluid volume deficit, maintaining a urine output of at least 30 mL/hour is a key indicator that the kidneys are receiving adequate blood flow and that fluid volume is being restored.
This outcome directly addresses the fluid deficit and serves as a measurable goal for fluid replacement therapy.
It takes priority over other choices because it directly reflects the patient's fluid status and the effectiveness of interventions to address the bleeding and fluid loss.
Correct Answer is D
Explanation
Choice A rationale:
Soaking the wound in an Epsom salt solution is not recommended for abscessed wounds. While Epsom salt has some potential benefits for wound healing, such as reducing inflammation and drawing out fluids, it can also be irritating to the skin and may actually worsen the abscess. Additionally, there's a risk of introducing bacteria from the Epsom salt into the wound, which could lead to further infection.
Choice B rationale:
Administering warm water sitz baths is not directly applicable to an abscessed leg wound. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or postpartum discomfort. They may help to soothe and cleanse the affected area, but they would not be effective in treating an abscess on the leg.
Choice C rationale:
Applying cold moist compresses is not the most appropriate intervention for an abscessed wound. Cold compresses can help to reduce pain and inflammation, but they can also constrict blood vessels and potentially hinder the healing process. Warm compresses are generally preferred for abscesses because they can help to promote drainage and healing.
Choice D rationale:
Applying warm moist compresses is the most appropriate nursing intervention for an abscessed leg wound. Warm compresses have several beneficial effects:
They promote vasodilation, which increases blood flow to the area and helps to deliver white blood cells and other healing agents to the site of infection.
They help to soften and loosen hardened pus, making it easier for the abscess to drain.
They provide a moist environment that promotes healing and prevents the wound from drying out. They can help to reduce pain and inflammation.
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