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Clinical Nurse Specialist CNS Adult Practice Test

Category - AACN Clinical Nurse Specialist Practice Test

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A client admitted for treatment of pressure ulcers on the left heel is being assessed by the nurse. The nurse documents that the wound is red, soft and bleeds easily, indicating second intention of wound healing. This wound type is managed by:
  1. Application of dry dressing
  2. Packing with wet sterile dressing and then covering with dry sterile dressing
  3. Tight packing with sterile saline dressing
  4. Lightly covering the wound with thin, dry gauze
Explanation
Answer: B - This type of wound is packed with sterile wet dressing and covered with dry sterile dressing to allow the drainage to adhere to the wet dressing. Second intention healing or granulation occurs when a wound is soft and red. The necrotic tissue fragments and what is left is a soft, reddish tissue that easily bleeds. The nurse must take care not to disturb the granulation by using dry and abrasive dressings. A dry dressing is more suitable for wounds that are closed by first intention healing or suturing.
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