Healing by Second Intention

QUESTION

20. For healing by second intention, a client’s wound has been packed with medicated dressings. During wo evaluation, which finding indicates that healing is taking place? O The surrounding tissue is red in color. O The wound drainage is serous. The skin around the wound is edematous. O The granulation tissue is at the wound edges. 21. A 20-year-old client is admitted for diarrhea. Which of the following is a nursing outcome? O bowel motility O fluid balance hardening of the stool prevent bleeding 22. A client with renal failure requires fresh frozen plasma as ordered by the physician. The nurse understands frozen plasma helps to: Decrease the risk for bleeding A reduction in severe abdominal distention Increase voiding (urine output) Increase Red Blood Cell Production 23. Passive immunity can be acquired in which of the following ways? check all answers t apply

ANSWER

20. Healing by Second Intention

Finding Indicating Healing: The finding that indicates healing is taking place in a wound healing by second intention is:

The granulation tissue is at the wound edges.

Granulation tissue is a key component of the wound healing process. It consists of new blood vessels, fibroblasts, and extracellular matrix, which help fill in the wound and promote tissue repair. The presence of granulation tissue at the wound edges suggests that the wound is progressing through the proliferative phase of healing.

21. Nursing Outcome for a Client with Diarrhea

Nursing Outcome: The nursing outcome for a 20-year-old client admitted for diarrhea can be:

Fluid Balance

Diarrhea can lead to significant fluid loss and dehydration. Monitoring and maintaining fluid balance are crucial nursing interventions to ensure the client’s hydration status is restored.

22. Fresh Frozen Plasma in Renal Failure

Purpose of Fresh Frozen Plasma: Fresh frozen plasma (FFP) is administered for various purposes, and in renal failure, it is primarily used to:

Increase Red Blood Cell Production

In renal failure, there can be a decrease in erythropoietin production, a hormone responsible for stimulating red blood cell production. FFP can provide clotting factors and proteins, including albumin, which may help in improving the overall condition of the client, potentially leading to increased red blood cell production.

23. Passive Immunity Acquisition

Ways to Acquire Passive Immunity: Passive immunity can be acquired through the following ways, and you can check all that apply:

Receiving Antibodies from Mother: Passive immunity can be acquired by newborns through the transfer of maternal antibodies across the placenta during pregnancy and through breastfeeding. This provides temporary protection to the infant.

Receiving Antibodies via Immune Serum: Passive immunity can also be acquired by receiving immune serum or immunoglobulin preparations containing antibodies against specific diseases. This is often done in cases of exposure to infectious diseases or for prophylaxis.

Transfusion of Preformed Antibodies: In certain medical situations, individuals may receive transfusions of preformed antibodies to rapidly address specific diseases or toxins.

Administration of Monoclonal Antibodies: Monoclonal antibodies, which are specific antibodies produced in the laboratory, can be administered to provide passive immunity against specific pathogens or diseases.

Passive immunity is short-lived and provides immediate protection but does not confer long-term immunity as active immunity (where the body produces its antibodies) does.

In summary, healing by second intention involves the presence of granulation tissue at the wound edges. A nursing outcome for a client with diarrhea is maintaining fluid balance. Fresh frozen plasma in renal failure can help increase red blood cell production. Passive immunity can be acquired through various means, including maternal antibodies, immune serum, transfusions, and monoclonal antibodies.