HESI RN PHARMACOLOGY PROCTORED EXAM
1. 1The nurse is caring for a patient in the burn unit. Which type of wound
healing will the nurse consider when planning care for this patient?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
ANS: B
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. A clean surgical incision is an example of a wound
with little loss of tissue that heals by primary intention. The skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repair is
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 for
several days, and then the wound edges are approximated. Wound closure is
delayed until the risk of infection is resolved.
2. A nurse is assessing a patient’s wound. Which nursing observation will
indicate the wound healed by secondary intention?
a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe
ANS: D
A wound healing by secondary intention takes longer than one healing by primary
intention. The wound is left open until it becomes filled with scar tissue. If the
scarring is severe, permanent loss of function often occurs. Wounds that heal by
primary intention heal quickly with minimal scarring. Scar tissue contains few
pigmented cells and has a lighter color than normal skin.
1
, 3. The nurse is caring for a patient who has experienced a total abdominal
hysterectomy. Which nursing observation of the incision will indicate the
patient is experiencing a complication of wound healing?
a. The site is hurting.
b. The site is approximated.
c. The site has started to itch.
d. The site has a mass, bluish in color.
ANS: D
A hematoma is a localized collection of blood underneath the tissues. It appears as
swelling, change in color, sensation, or warmth or a mass that often takes on a
bluish discoloration. A hematoma near a major artery or vein is dangerous because
it can put pressure on the vein or artery and obstruct blood flow. Itching is not a
complication. Incisions should be approximated with edges together; this is a sign
of normal healing. After surgery, when nerves in the skin and tissues have been
traumatized by the surgical procedure, it is expected that the patient will
experience pain.
4. A nurse is caring for a postoperative patient. Which finding will alert the
nurse to a potential wound dehiscence?
a. Protrusion of visceral organs through a wound opening
b. Chronic drainage of fluid through the incision site
c. Report by patient that something has given way
d. Drainage that is odorous and purulent
ANS: C
Patients often report feeling as though something has given way with dehiscence.
Dehiscence occurs when an incision fails to heal properly and the layers of skin
and tissue separate. It involves abdominal surgical wounds and occurs after a
sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is seen
when vital organs protrude through a wound opening. When there is an increase in
serosanguineous drainage from a wound in the first few days after surgery, be alert
for the potential for dehiscence. Infection is characterized by drainage that is
odorous and purulent.
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1. 1The nurse is caring for a patient in the burn unit. Which type of wound
healing will the nurse consider when planning care for this patient?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
ANS: B
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. A clean surgical incision is an example of a wound
with little loss of tissue that heals by primary intention. The skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repair is
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 for
several days, and then the wound edges are approximated. Wound closure is
delayed until the risk of infection is resolved.
2. A nurse is assessing a patient’s wound. Which nursing observation will
indicate the wound healed by secondary intention?
a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe
ANS: D
A wound healing by secondary intention takes longer than one healing by primary
intention. The wound is left open until it becomes filled with scar tissue. If the
scarring is severe, permanent loss of function often occurs. Wounds that heal by
primary intention heal quickly with minimal scarring. Scar tissue contains few
pigmented cells and has a lighter color than normal skin.
1
, 3. The nurse is caring for a patient who has experienced a total abdominal
hysterectomy. Which nursing observation of the incision will indicate the
patient is experiencing a complication of wound healing?
a. The site is hurting.
b. The site is approximated.
c. The site has started to itch.
d. The site has a mass, bluish in color.
ANS: D
A hematoma is a localized collection of blood underneath the tissues. It appears as
swelling, change in color, sensation, or warmth or a mass that often takes on a
bluish discoloration. A hematoma near a major artery or vein is dangerous because
it can put pressure on the vein or artery and obstruct blood flow. Itching is not a
complication. Incisions should be approximated with edges together; this is a sign
of normal healing. After surgery, when nerves in the skin and tissues have been
traumatized by the surgical procedure, it is expected that the patient will
experience pain.
4. A nurse is caring for a postoperative patient. Which finding will alert the
nurse to a potential wound dehiscence?
a. Protrusion of visceral organs through a wound opening
b. Chronic drainage of fluid through the incision site
c. Report by patient that something has given way
d. Drainage that is odorous and purulent
ANS: C
Patients often report feeling as though something has given way with dehiscence.
Dehiscence occurs when an incision fails to heal properly and the layers of skin
and tissue separate. It involves abdominal surgical wounds and occurs after a
sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is seen
when vital organs protrude through a wound opening. When there is an increase in
serosanguineous drainage from a wound in the first few days after surgery, be alert
for the potential for dehiscence. Infection is characterized by drainage that is
odorous and purulent.
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