NR-324 Adult Health I - Set 5 - Part 2

Correct Answer: Healing by tertiary intention, a delayed closure

Tertiary intention, also called delayed primary closure, describes a contaminated wound left open until infection is controlled and then sutured. Two granulating surfaces are brought together, which is exactly what this surgeon plans. Option a is incorrect because primary intention means the edges were approximated at the time of surgery. This wound sat open for days first, which is the defining difference between the two. Option b is incorrect because secondary intention leaves the wound open permanently, to fill with granulation from the base upward and close by contraction. A planned surgical closure changes the classification. Option d is incorrect because only injury limited to the epidermis regenerates without scar. A full thickness contaminated abdominal wound destroys the dermal appendages, so repair produces scar tissue in every case.

Correct Answer: Fat embolism syndrome from the fractured femur

Hypoxemia, altered mental status and a petechial rash within one to two days of a long bone fracture form the classic triad of fat embolism syndrome. Marrow fat has reached the pulmonary capillaries. Option a is incorrect because a thrombotic embolus usually arrives days to weeks into immobility and produces no rash. Pleuritic chest pain and calf findings would point that way instead. Option c is incorrect because a closed fracture offers no portal for organisms, and sepsis would bring fever with warm flushed skin rather than scattered petechiae on the chest and eyes. Option d is incorrect because hemorrhage would show hypotension, pallor and a falling hemoglobin without confusion tied to hypoxemia. Bleeding also does not scatter pinpoint lesions over the chest and conjunctivae.

Correct Answer: Splint the incision with a pillow when coughing.

Coughing spikes intra abdominal pressure against a wound that has little tensile strength. Supporting the incision with a pillow or folded blanket absorbs that force and is a leading way to prevent dehiscence. Option b is incorrect because suppressing coughing and deep breathing causes alveolar collapse, retained secretions and pneumonia. The client coughs, but does so with the incision supported so the force is absorbed. Option c is incorrect because rubbing a fresh surgical wound traumatizes new tissue and can introduce organisms. Nothing is massaged over an incision or over reddened skin in the early postoperative period. Option d is incorrect because a dry scab blocks epithelial migration, and cells must then burrow beneath it. A clean surgical dressing stays in place for the first day or two after surgery.

Correct Answer: "Use them for every client in every setting."

Standard precautions apply to every client, in every setting, at all times, regardless of diagnosis. Clients transmit during incubation and prodrome and carriers transmit indefinitely, so infectious status can never be known in advance. Option a is incorrect because waiting for a confirmed diagnosis leaves staff unprotected during the days before results return. Many clients who transmit organisms are never diagnosed at all, which is the reason the baseline covers everyone. Option b is incorrect because the rule covers all body fluids, secretions and excretions except sweat, plus non-intact skin and mucous membranes. Restricting it to anticipated blood exposure omits urine, stool, wound drainage and respiratory secretions. Option c is incorrect because transmission-based precautions are layered on top of the baseline rather than substituted for it. Every isolation category is standard plus something extra, so the baseline never switches off for any client.

Correct Answer: Healing by primary intention with minimal scarring

Primary intention occurs when wound margins are neatly approximated, as in a sutured incision. Tissue loss is minimal, only a small amount of granulation tissue is needed, and the resulting scar is thin and linear. Option a is incorrect because secondary intention applies to wounds left open because tissue loss prevents the edges from meeting. This incision was closed, so no large defect needs filling from below. Option c is incorrect because tertiary intention requires a deliberate delay, with the wound left open until contamination is controlled and then sutured. The surgeon closed this wound in the operating room. Option d is incorrect because every wound passes through hemostasis and inflammation regardless of how the edges are managed. Only superficial epidermal injury regenerates completely, and a sutured incision extends far deeper.

Correct Answer: Inspect the incision and notify the surgeon.

A sudden increase in serosanguineous drainage from a previously dry incision around the fifth postoperative day signals impending dehiscence until proven otherwise. The nurse must see the wound and report it to the surgeon. Option a is incorrect because adding gauze conceals the very finding that needs evaluation. Reinforcing without looking delays recognition of separated deep layers, which can progress to complete separation and protruding viscera. Option b is incorrect because serosanguineous drainage is expected only in the first days and in small amounts. A dressing that soaks through after being dry, following a popping sensation, is not normal. Option d is incorrect because walking raises intra abdominal pressure against a wound that may already have separated. This client needs to lie still with the knees bent, not to move about.

Correct Answer: The client is responding well to therapy

A rising helper cell count with a falling viral load is the picture of effective treatment. The client's own defenses are recovering while the amount of circulating virus drops below detection. Option a is incorrect because undetectable never means eliminated. The integrated virus stays in reservoirs, and replication resumes if the drugs stop, which is why therapy continues for life. Option c is incorrect because suppression is the reason to continue, not a reason to stop. Interrupting the regimen allows rebound within weeks and invites resistant strains to take hold. Option d is incorrect because these two values moving in opposite directions are exactly what successful therapy produces. Doubting accurate results would delay the praise and reinforcement the client has earned.

Correct Answer: Limit organ meats, shellfish and beer

Organ meats, shellfish and alcohol, especially beer, are high in purines that break down to uric acid. Cutting them back, along with generous fluid intake and weight control, lowers the risk of another flare. Option a is incorrect because fasting and crash dieting raise uric acid. Keto acids produced during starvation compete with urate for excretion by the kidney, which is a well known trigger for an attack. Option b is incorrect because fluids are increased rather than limited in gout. Good hydration supports renal excretion of uric acid, and restricting intake concentrates urate and makes crystal formation more likely. Option d is incorrect because liver and sardines sit near the top of the high purine list. Adding them would push urate higher and invite the very attack the client wants to avoid.

Correct Answer: Give intramuscular epinephrine in the outer thigh

Epinephrine is the first drug in anaphylaxis and nothing precedes it. Given intramuscularly into the anterolateral thigh, it reverses bronchoconstriction, restores blood pressure through vasoconstriction and limits further mediator release. Stridor signals an airway closing within minutes. Option b is incorrect because antihistamines block receptors that histamine has already occupied and left. Diphenhydramine relieves urticaria and pruritus but does nothing for laryngeal edema or distributive shock, so it follows epinephrine rather than replacing it. Option c is incorrect because nebulized albuterol reaches the lower airway and cannot open an upper airway narrowed by laryngeal edema. It is reserved for wheeze that persists after epinephrine has already been given. Option d is incorrect because corticosteroids act too slowly to help a client whose airway is closing now. Their target is the late-phase reaction hours afterward, which makes them an adjunct in a true emergency.

Correct Answer: Place a surgical mask on the client

A transported client wears a surgical mask, never a respirator. The mask contains the client's own droplet nuclei at the source, and a respirator is uncomfortable, unnecessary for source control and harder for a breathless client to tolerate. Option a is incorrect because the respirator protects the wearer from inhaling particles, which is the staff need rather than the client's. Fit testing was never performed on this client, so the seal could not be verified anyway. Option b is incorrect because necessary diagnostic studies proceed with source control in place. Delaying imaging until a months long drug regimen finishes would withhold information needed to guide treatment of the very infection being contained. Option c is incorrect because tuberculosis travels in inhaled droplet nuclei, not by touch. Gown and gloves address contact spread and add nothing here, while leaving the client's exhaled particles free to enter corridor air.

Correct Answer: Ice the ankle for about twenty minutes

Rest, ice, compression and elevation govern the first day or two. Cold is applied for fifteen to twenty minutes at a time, repeated often, and the ankle is raised above heart level to drain swelling. Option a is incorrect because heat belongs after the first forty eight hours, once bleeding into the tissue has stopped. Early warmth dilates vessels and adds to the swelling and bruising around the joint. Option b is incorrect because an elastic bandage is wrapped from the toes upward so that fluid is pushed toward the heart. Starting at the calf traps venous blood and lymph in the foot. Option d is incorrect because a dependent foot fills with interstitial fluid and swells more. Raising the ankle above the level of the heart lets gravity drain that fluid during the acute phase.

Correct Answer: These findings reflect the local inflammatory response.

Redness, heat, swelling, pain and loss of function are the five local manifestations of inflammation. Vasodilation produces the redness and heat, increased capillary permeability produces the swelling, and swelling with pain limits movement. Option b is incorrect because inflammation follows injury of any kind, and a closed twisting injury involves no organism. Infection always inflames, but inflammation frequently occurs without any microorganism present. Option c is incorrect because chronic inflammation develops over weeks to years and shows fatigue, weight loss and fibrosis rather than dramatic local signs. This injury happened two hours ago. Option d is incorrect because reduced arterial flow produces pallor, coolness and diminished pulses. Warmth and bounding redness come from vasodilation, which is the opposite of what ischemic tissue shows.

Correct Answer: Chart it as a healing Stage four injury.

A pressure injury is never reverse staged. Lost muscle and fat are not regenerated, so the defect fills with granulation tissue and then scar. The stage stays at the deepest level reached and progress is shown by measurements. Option a is incorrect because a shallower wound does not mean lost anatomy returned. Charting a lower number understates what the client survived and hides how much care this site still requires. Option b is incorrect because there are no intermediate stages during healing. Granulation tissue is not subcutaneous fat, so describing the filled wound as fat level damage misrepresents what the tissue actually is. Option c is incorrect because unstageable means the base is hidden by slough or eschar. This base is visible and granulating, so nothing prevents the original stage from remaining on the record.

Correct Answer: Arrange immediate evaluation for these new findings

Loss of bowel control, saddle numbness and weakness in both legs describe cauda equina syndrome, a surgical emergency. Delay risks permanent loss of bladder, bowel and leg function, so the client is evaluated at once. Option a is incorrect because bed rest is not recommended even for ordinary back strain, since it weakens the supporting muscles and slows recovery. Here it would also delay care for a true emergency. Option c is incorrect because comfort measures suit uncomplicated strain, not a client with new incontinence and numbness of the perineum. Those findings are red flags that change the plan entirely. Option d is incorrect because waiting two weeks wastes the window in which nerve function can still be saved. Imaging is usually deferred in simple back pain, but red flag symptoms call for prompt assessment.

Correct Answer: Record the drainage and recompress the bulb.

Sanguineous drainage is expected in the first hours after surgery. The bulb must be emptied, measured and compressed flat before the cap is replaced, because a bulb left expanded exerts no suction. Option a is incorrect because bright red output is the expected first stage of drainage, which progresses to serosanguineous and then serous. Clamping a drain also requires a specific order. Option b is incorrect because a drain is never irrigated without a specific order from the surgeon. Flushing the tubing could introduce organisms into the surgical cavity the drain is protecting. Option c is incorrect because an expanded bulb becomes a passive tube rather than a suction device. Fluid then collects in the wound bed, separating tissue layers and raising the infection risk.

Correct Answer: The virus remains in reservoirs, so the drugs continue for life

Undetectable means the circulating virus is below the assay limit, not eliminated. Integrated virus persists in reservoirs and rebounds if therapy stops, so treatment is lifelong even while sustained suppression prevents sexual transmission. Option a is incorrect because no tapering schedule exists for antiretroviral therapy. Lowering the dose creates exactly the partial drug pressure that breeds resistant virus, and resistance cannot be undone. Option c is incorrect because repeated suppressed results show the regimen is working rather than signaling that it can end. Stopping at any point allows the viral load to climb again within weeks. Option d is incorrect because the assay is accurate; it simply cannot measure below a set threshold. Doubting the laboratory would undercut the client's confidence in the very result that proves success.

Correct Answer: Cell-mediated immunity carried by T lymphocytes

Cell-mediated immunity uses T lymphocytes to attack virus-infected cells, fungi, intracellular organisms such as Mycobacterium tuberculosis, tumor cells and grafted tissue. Recurrent fungal disease and reactivated tuberculosis point directly at a failure of this arm. Option a is incorrect because humoral immunity fails with recurrent bacterial infections, not fungal or mycobacterial ones. B lymphocytes and the antibodies they release work best against bacteria, bacterial toxins and free virus in the blood. Option b is incorrect because a T lymphocyte disorder lies within the adaptive system, not the innate one. Skin, mucous membranes, cilia and gastric acid belong to innate defense and are unaffected by a lymphocyte abnormality. Option d is incorrect because complement is a set of plasma proteins within the innate response that amplifies inflammation and lyses organisms. It is not an arm of adaptive immunity, and it acts identically against every organism.

Correct Answer: Combination antiretroviral drugs started within 72 hours

Post exposure prophylaxis is a multidrug antiretroviral regimen started as soon as possible and no later than three days after exposure, then continued for four weeks with follow up testing. Option b is incorrect because one dose cannot suppress virus during the days when infection is being established. The regimen runs for a full four weeks, not a single administration. Option c is incorrect because waiting for source or baseline results wastes the narrow window in which prophylaxis works. Treatment begins at once and is stopped later if the source proves negative. Option d is incorrect because a low transmission risk from one percutaneous exposure is not zero risk. Prophylaxis, source testing and scheduled follow up exist precisely because the small chance is real.

Correct Answer: "I will use a raised seat on the toilet."

A raised toilet seat keeps the hip flexed less than ninety degrees. The same rule drives the firm high chair, the reacher and the sock aid, and it blocks the deep flexion that dislocates the joint. Option a is incorrect because a soft low recliner drops the hips below the knees and carries the joint past ninety degrees of flexion. A firm chair with armrests is the safe choice. Option c is incorrect because crossing the ankles adducts the leg past midline, one of the three movements that lever the prosthetic head out of its cup. An abduction pillow is used in bed. Option d is incorrect because bending forward at the waist flexes the hip far beyond the limit and is a classic cause of dislocation. A long handled shoehorn and sock aid replace that movement.

Correct Answer: Keep the eschar dry and offload the heel.

Stable eschar on the heel acts as the body's natural biologic cover. The heel has almost no padding and often poor arterial supply, so the eschar is left dry and intact and the heel is offloaded and inspected daily. Option b is incorrect because adding moisture softens the eschar and starts autolytic debridement, which is exactly what must be avoided here. A softened heel eschar opens a poorly perfused wound that may never close. Option c is incorrect because sharp debridement is reserved for spreading infection, sepsis or extensive necrosis. None of those findings is present, and cutting away this cover would create a large open ulcer. Option d is incorrect because saline gauze allowed to dry removes tissue without selecting it, taking healthy structures along with dead ones. It also rehydrates the very crust that is protecting this heel.