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A nurse is teaching a newly licensed nurse about wound healing by
secondary intention. Which of the following statements by the newly
licensed nurse indicates an understanding of healing by secondary
intention?
A. "This type of healing carries a lower risk of infection than others."
B. "This type of healing begins in the wound bed with the generation of
granulation tissue."
C. "These wounds heal faster than those that heal by other processes."
D. "These wounds require a dry wound bed in order for healing to
occur."
B
,A nurse is caring for a client who has sustained a gunshot wound to
the abdomen and is 6 hr postoperative. The nurse notices protrusion
of the client's organs from the incision site and calls for help. Which of
the following actions should the nurse take?
A. Ask the client to bear down and cough.
B. Ask another nurse to bring icepacks to apply to the wound.
C. Cover the client's wound with a sterile saline dressing.
D. Place the client in high-Fowler's position.
C
A nurse is observing an assistive personnel (AP) care for a client.
Which of the following actions by the AP places the client at risk for
alterations in skin integrity?
A. The AP places the client in high-Fowler's position.
B. The AP places pillows under the client's lower extremities.
C. The AP feeds the client 80% of each meal.
D. The AP cleans and dries the client's perineum after each episode of
incontinence.
A
,A nurse is providing teaching for a client who has a prescription for an
alginate dressing for a wound. Which of the following statements by
the client indicates an understanding of an alginate dressing?
A. "The dressing will need to be changed every 24 hours."
B. "This type of dressing is used in small wounds with small amounts of
drainage."
C. "This dressing may develop a foul-smelling, yellow, gelatinous film on
its underside as bacteria are trapped."
D. "This type of dressing will need a secondary dressing for
reinforcement."
D
A nurse is reviewing strategies to reduce the risk of wound dehiscence
with a client following abdominal surgery. Which of the following
responses by the client indicates an understanding of the
information?
A. "I should expect a small separation along the incision line."
B. "If I feel like something popped, I should sit up in bed."
C. "I should report pain at my wound site."
D. "Recurrent vomiting is expected after surgery."
C
, A nurse has completed the Braden scale on four clients who are at risk
for alterations in skin integrity. Which of the following clients should
the nurse recognize as having the greatest risk for altered skin
integrity?
A. A client who has a Braden Scale score of 9
B. A client who has a Braden Scale score of 23
C. A client who has a Braden Scale score of 12
D. A client who has a Braden Scale score of 15
A