Elimination, Nutrition, and Blood
Glucose Monitoring - Questions,
Correct Answers and Detailed
Explained Rationales|Latest Update
Wound Care Essentials - Example Q1
Question: A nurse is changing a dressing for a client with a surgical incision. The wound has
approximated edges and no drainage. How should the nurse document this wound?
A) Open wound with purulent drainage
B) Closed surgical wound healing by primary intention
C) Chronic wound healing by secondary intention
D) Pressure injury stage 2
Correct Answer: B
Detailed Explained Rationale: The correct answer is B – Closed surgical wound healing by
primary intention. A surgical incision with approximated edges that is closed with
sutures/staples heals by primary intention. This is the fastest type of healing with minimal
scarring.
Why others are wrong: A is wrong because purulent drainage indicates infection, which is
not described. C is wrong because secondary intention is for open wounds that must
granulate from bottom up, like pressure ulcers – not a closed incision. D is wrong because
stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis, not a surgical
incision.
Bowel Elimination - Example Q2
Question: A client reports not having a bowel movement for 3 days, abdominal cramping,
and hard stool. The nurse reviews medications and notes opioid use. What is the priority
nursing intervention?
A) Encourage high fiber diet and increase fluids to 2000 mL/day if not contraindicated,
and ambulate
B) Insert an indwelling urinary catheter
C) Restrict fluids
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