Hesi Fundamentals Proctored Exam.

The nurse should see the patient with an appendicitis first. Warm applications are contraindicated when the patient has an acute, localized inflammation such as appendicitis because the heat could cause the appendix to rupture. Although a Stage IV pressure ulcer is deep, it is not as critical as the appendicitis patient. The total Braden score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. A score of 18 can be assessed later. A healing incision is approximated (closed); this is a normal finding and does not need to be seen first.5.Thenurseiscaringforapatientwhoisexperiencingafull-thicknessrepair.Whichtypeoftissuewillthe nurse expect to observe when the wound ishealing?a.Escharb.Sloughc.Granulationd.PurulentdrainageANS: CGranulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.6.Thenurseiscaringforapatientwhohasexperiencedalaparoscopicappendectomy.Forwhichtypeof healing will the nurse focus the careplan?a.Partial-thicknessrepairb.Secondaryintentionc.Tertiaryintentiond.PrimaryintentionANS: DA clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, 186 and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open forseveral days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater