Wound Healing

Every question here, with the answer

1. A postoperative patient with an abdominal incision states, “It feels like something has given way.” The nurse sees that the wound has completely separated and viscera are protruding. Which action is most appropriate?

   1. Place the patient in low Fowler position and cover the area with a sterile towel soaked with sterile 0.9 percent sodium chloride.
   2. Assist the patient to ambulate to reduce the risk of further complications.
   3. Irrigate the wound repeatedly to remove bacteria and cellular debris.
   4. Apply heat therapy to increase perfusion to the wound edges.

   Answer: Place the patient in low Fowler position and cover the area with a sterile towel soaked with sterile 0.9 percent sodium chloride.

   This finding is evisceration and should be treated as a medical emergency. Low Fowler positioning with the knees slightly bent lowers intra-abdominal pressure, and a sterile saline-soaked towel protects the exposed area until surgical intervention occurs. Ambulation, repeated irrigation, or heat therapy do not match the emergency management described in the section.

2. A patient has a pressure injury with significant tissue loss, and the wound edges cannot be easily approximated. Which type of wound healing should the nurse expect?

   1. Tertiary intention healing
   2. Hemostasis
   3. Primary intention healing
   4. Secondary intention healing

   Answer: Secondary intention healing

   Pressure injuries are examples of secondary intention healing because extensive tissue loss makes edge approximation difficult. This type of healing takes longer and has more scarring and greater susceptibility to infection. Primary intention involves approximated edges, tertiary intention involves delayed closure, and hemostasis is a phase of healing rather than a type of intention healing.

3. A nurse is reviewing a care plan for a patient whose wound healing is delayed. Which findings are systemic wound healing factors the nurse should consider? Select all that apply.

   1. Smoking or alcohol use
   2. Poor oxygenation
   3. Diabetes
   4. Advanced age
   5. Desiccation of the wound bed from exposure to air

   Answer: Smoking or alcohol use, Poor oxygenation, Diabetes, Advanced age

   Systemic factors occur throughout the body and include age, poor oxygenation, diabetes, and smoking or alcohol use. Desiccation directly affects the wound bed and is identified as a localized factor. Distinguishing systemic from localized factors helps guide appropriate wound management.

4. A patient with a sutured wound is in the proliferation phase of healing and asks whether it is safe to pick up a heavy object. Which response by the nurse is best?

   1. “You may lift heavy objects once the wound looks lighter in appearance.”
   2. “Heavy lifting is encouraged because it increases collagen synthesis.”
   3. “The wound should be left open to air before lifting anything heavy.”
   4. “Avoid heavy lifting because strain can adversely affect the injury site.”

   Answer: “Avoid heavy lifting because strain can adversely affect the injury site.”

   During the proliferation phase, wounds closed with sutures or other closures should be protected from strain such as heavy lifting. The section does not describe heavy lifting as helpful, and leaving the wound open to air is dependent on wound type rather than a general safety measure. A lighter wound appearance does not mean strain is safe.

5. A patient with a visible wound says they are afraid others will reject them and worries about exposure during wound care. Which nursing interventions are appropriate? Select all that apply.

   1. Exhibit empathy and acceptance
   2. Answer the patient’s questions honestly and accurately
   3. Tell the patient not to discuss the wound because fear is common
   4. Prevent excessive exposure of body parts during care
   5. Encourage the patient to express feelings during therapeutic conversation

   Answer: Exhibit empathy and acceptance, Answer the patient’s questions honestly and accurately, Prevent excessive exposure of body parts during care, Encourage the patient to express feelings during therapeutic conversation

   The section recommends therapeutic conversation, honest and accurate answers, empathy and acceptance, and preventing excessive exposure during care. Telling the patient not to discuss the wound would not encourage expression of feelings and does not align with the recommended interventions. These actions address fear, privacy concerns, and emotional stress related to wounds.