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The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?
- A. Late intention
- B. Second intention
- C. Third intention
- D. First intention
Correct Answer: C
Rationale: Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.
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The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?
- A. Day 9
- B. Day 7
- C. Day 5
- D. Day 3
Correct Answer: C
Rationale: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.
The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
- A. Presence of an indwelling urinary catheter
- B. Rectal temperature of 99.5 F (37.5 C)
- C. Red, warm, tender incision
- D. White blood cell (WBC) count of 8,000 /mL
Correct Answer: C
Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5 F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000 /mL.
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
- A. Describe the appearance of the dressing in the electronic health record
- B. Photograph the patients abdomen for later comparison using a smartphone
- C. Trace the outline of the drainage on the dressing for future comparison
- D. Remove and weigh the dressing, reapply it, and then repeat in 8 hours
Correct Answer: C
Rationale: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.
The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?
- A. Ill make sure to limit my intake of protein
- B. Ill make sure that the bandage is wrapped tightly
- C. My foot should feel cool or cold while my legs healing
- D. Ill eat plenty of fruits and vegetables
Correct Answer: D
Rationale: Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound healing.
The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?
- A. Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment
- B. Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw
- C. Assess the arterial pulses, and place the patient in the Trendelenburg position
- D. Reintubate the patient
Correct Answer: B
Rationale: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.