A new nurse reads a client has a wound “healing by second intention” and asks what that means. Which description by the charge nurse is most accurate?

Correct Answer: C

Rationale: The correct answer is C because healing by second intention refers to a wound that is left open to fill in with granulation tissue. This process allows for the wound to heal from the inside out, promoting tissue regeneration. Explanation: 1. Option A is incorrect because healing by second intention does not involve approximating or stitching wound edges together. 2. Option B is incorrect because stapling a wound after an infection does not necessarily relate to healing by second intention. 3. Option D is incorrect because although the wound may be contaminated, healing by second intention does not mean it cannot be closed at all. In summary, the correct answer is C because it accurately describes the process of healing by second intention, which involves allowing an open wound to fill in with granulation tissue.

Correct Answer: D

Rationale: The correct answer is D: Spironolactone (Aldactone). Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia due to its mechanism of action, which inhibits aldosterone. Aldosterone promotes potassium excretion, so inhibiting it can lead to potassium retention and hyperkalemia. Hydrochlorothiazide (A) is a thiazide diuretic that can actually cause hypokalemia. Furosemide (B) is a loop diuretic that also can lead to hypokalemia by increasing potassium excretion. Acetazolamide (C) is a carbonic anhydrase inhibitor diuretic and is not associated with significant effects on potassium levels.

Correct Answer: D

Rationale: The correct answer is D: Decreased cardiac output. In a patient with STEMI, a low blood pressure and high heart rate indicate decreased cardiac output, which is a life-threatening condition. Addressing this issue is crucial to prevent further complications like cardiogenic shock. Anxiety (A), acute pain (B), and stress management (C) are important but not immediate priorities in this scenario. Managing the patient's hemodynamic stability is paramount to ensure adequate tissue perfusion and prevent further deterioration.

Correct Answer: B

Rationale: The correct answer is B: Echocardiography. This is because echocardiography is a non-invasive imaging test that can help visualize the pericardium and assess for signs of pericarditis. It can show if there is fluid around the heart or any inflammation. Blood cultures (A) are not typically used to diagnose pericarditis, as it is not an infectious process. Cardiac catheterization (C) is an invasive procedure used to evaluate coronary artery disease, not pericarditis. 24-hour Holter monitor (D) is used to monitor heart rhythms over a period of time and is not typically used in the initial diagnosis of acute pericarditis.

Correct Answer: C

Rationale: The correct answer is C because during an acute episode of respiratory distress, it is essential to quickly gather specific information about the current situation. This allows the nurse to assess the severity of the issue, identify potential causes, and provide immediate interventions. Asking specific questions about the episode helps in determining the onset, triggers, associated symptoms, and any previous similar episodes. This information guides the nurse in prioritizing care and initiating appropriate interventions promptly. Choice A is incorrect because asking the patient to lie down for a full physical assessment is not appropriate during acute respiratory distress as it delays crucial information gathering. Choice B is incorrect as completing the health history and checking for allergies can be done after addressing the immediate respiratory distress. Choice D is incorrect because delaying the physical assessment for pulmonary function tests is not indicated in the acute management of respiratory distress.