A home care nurse is caring for a client who is recovering from ...

[joesmith1212]

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. The client's surgical wound has staples that are aiding in the wound healing.
 
  When documenting this client's care, which terminology best describes this client's care?
  A) Primary intention healing
  B) Secondary intention healing
  C) Tertiary intention healing
  D) Quaternary intention healing

Question 2

A client has a wound of the left lateral aspect of the thigh. Which action by the nurse promotes wound healing for this client?
 
  A) Positioning to keep weight off of the wound
  B) Positioning with weight directly on the wound
  C) Restricting fluids
  D) Enforcing strict bedrest

[jessicaduplan]

Answer to Question 1

Answer: C

A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.

Answer to Question 2

Answer: A

To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.