A nurse is planning care for a client who has a surgical incision with staples. Which intervention should the nurse include in the plan to prevent wound dehiscence?

Correct Answer: B

Rationale: Instructing the client to splint the incision when coughing is the correct intervention to prevent wound dehiscence the separation of wound layers. Coughing increases intra-abdominal pressure, stressing staples, and splinting with a pillow or hands reduces tension, protecting the closure. Steri-strips approximate edges but lack the strength to prevent dehiscence under pressure, used more for minor wounds. Changing dressings every 8 hours prevents infection but doesn't address mechanical stress, and frequency depends on drainage, not a fixed schedule. Irrigating with saline cleanses but risks disrupting healing tissue, unrelated to dehiscence prevention. Splinting directly counters physical strain, aligning with post-surgical care to maintain incision integrity and promote healing.

Correct Answer: D

Rationale: All of the above,' as age, amount of underlying tissue, and illness all influence skin integrity resistance. Age (A) affects skin thickness and elasticity elderly skin thins, losing resilience, while youthful skin is more robust. Amount of underlying tissue (B), like subcutaneous fat, cushions and protects skin; less tissue increases vulnerability to breakdown, as in malnourishment. Illness (C) weakens skin through impaired immunity or circulation, as in diabetes or infection, reducing repair capacity. Each factor independently impacts durability, and together, they compound risk, making 'All of the above' correct. In nursing, this holistic view guides risk assessment e.g., an elderly, thin patient with chronic illness is prone to ulcers. No single factor suffices; their synergy is critical, distinguishing D as the comprehensive choice per wound care principles.

Correct Answer: C

Rationale: Neutrophil,' as neutrophils are the primary white blood cells in the inflammatory phase of wound healing. They arrive first (within hours), phagocytosing bacteria and debris to prevent infection, peaking early in this phase. 'Leukocyte' is a broad term including all white cells (neutrophils, macrophages), but the question seeks specificity neutrophils dominate initially. 'Macrophage' arrives later, clearing debris and aiding repair, but isn't first. 'A and B' is too vague, missing neutrophils' primacy. In nursing, recognizing neutrophils' role guides infection monitoring elevated counts signal inflammation. The inflammatory phase's early focus on bacterial defense highlights C, distinguishing it from broader or later-acting cells.

Correct Answer: C

Rationale: It depends,' as a pressure ulcer can be acute or chronic depending on its duration and healing trajectory. Acute pressure ulcers form quickly from intense, short-term pressure (e.g., post-surgery immobility) and may heal with prompt relief. Chronic pressure ulcers persist over weeks or months, often in immobile patients with comorbidities like diabetes, staying in the inflammatory phase. 'Acute wound' alone doesn't account for chronic cases. 'Chronic wound' excludes acute ones. 'None of the above' dismisses valid variability. In nursing, this distinction guides care acute ulcers need immediate pressure relief, chronic ones require ongoing management (e.g., debridement). The question's broad scope demands flexibility, making C the accurate choice reflecting pressure ulcers' context-dependent nature.