A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:

Correct Answer: A

Rationale: Primary intention is the correct answer as it describes wound healing where the edges are well approximated, such as with sutures, and there's minimal tissue loss or drainage, leading to fast healing with minimal scarring. This typically occurs in clean, surgical incisions where the body can efficiently close the wound through epithelialization. Secondary intention occurs when wound edges are not approximated, often due to significant tissue loss or infection, healing through granulation tissue formation, which takes longer and results in more scarring. Tertiary intention involves a delay in closure, often intentionally left open for drainage or debridement before suturing, resulting in intermediate scarring. Quaternary intention is not a recognized term in wound healing classifications. The scenario's description of well-approximated edges and minimal drainage aligns with primary intention, reflecting an optimal healing process under controlled conditions.

Correct Answer: C

Rationale: Immobilizing the right arm with a splint or sling is the correct answer, as it promotes graft adherence by preventing movement and shear forces that could dislodge the newly placed skin graft. Stability is critical in the initial days post-grafting to allow the graft to establish blood supply from the wound bed, ensuring survival and integration. Elevation may reduce edema but isn't the primary intervention for adherence, though it can aid comfort and swelling control. Applying negative pressure wound therapy is contraindicated for grafts, as suction could disrupt fragile tissue, cause bleeding, or lift the graft, undermining its purpose. Irrigation with saline twice daily risks disturbing the graft's attachment and introduces infection risk, countering sterile post-op protocols that favor minimal interference. Immobilization directly addresses the mechanical stability needed for graft take, making it the most effective nursing action in this scenario, supported by standard wound care principles.

Correct Answer: B

Rationale: Yellowish-green drainage is the correct finding to report to the wound care specialist, as it strongly suggests infection or necrosis in the pressure ulcer. This purulent exudate, often tied to bacterial presence like Pseudomonas or Staphylococcus, requires urgent evaluation, possibly a culture, and treatment to prevent worsening or systemic spread. Foul odor may hint at infection or anaerobic bacteria but isn't definitive alone, as some wounds smell without being infected, making it less specific. Granulation tissue is a positive healing sign, not a concern, indicating new tissue formation. Partial-thickness skin loss aligns with pressure ulcer staging (e.g., Stage 2) and isn't an acute issue to report unless deteriorating. The yellowish-green drainage stands out as a critical, actionable finding, necessitating specialist input to address potential infection and optimize care.

Correct Answer: C

Rationale: Increased pain and tenderness is the correct answer, indicating a possible infection in the pressure ulcer. Infection triggers an inflammatory response, heightening nerve sensitivity and causing more pain and tenderness, a shift from baseline that warrants a culture and provider input. Serous drainage is normal clear and watery unless it turns cloudy or purulent, which isn't specified here. Reddened periwound skin reflects healing-related blood flow, not infection, unless spreading or hot. Granulation tissue signifies healthy repair, not infection, unless it's pale or deteriorating. Pain and tenderness stand out as infection markers, as bacteria amplify inflammation, distinguishing this finding in a wound assessment and signaling a need for further investigation.

Correct Answer: D

Rationale: 16,800 mL, based on the Parkland formula for burn fluid resuscitation: 4 mL of lactated Ringer's per kg of body weight per percentage of TBSA burned, given over 24 hours (half in the first 8 hours, half in the next 16). For a 70 kg client with 30% TBSA: 4 mL × 70 kg × 30 = 8,400 mL. However, the total 24-hour volume is often miscalculated; the formula yields 8,400 mL correctly, but the question's options suggest a doubled intent, possibly an error. Assuming intent aligns with standard Parkland (8,400 mL), none match perfectly, yet D (16,800 mL) might reflect a misprint. Still, 8,400 mL is accurate: 4,200 mL first 8 hours, 4,200 mL next 16. Given options, D is closest to a plausible high-end miscalculation, but 8,400 mL is technically right.