Nursing Fundamentals & Patient Care Flashcards

Which type of wound healing occurs when wound edges are approximated with sutures or staples?

Answer: Primary intention

Healing by primary intention (first intention) occurs when wound edges are cleanly approximated, minimizing tissue loss and scarring. Examples include surgical incisions closed with sutures. It is the fastest form of wound healing.

A patient's wound is draining thick, yellow-green fluid. How should the nurse document this finding?

Answer: Purulent drainage

Purulent drainage is thick, opaque, and yellow-green in color, indicating bacterial infection and leukocyte activity. Serous is clear/watery, serosanguineous is pink-tinged, and sanguineous is bright red (fresh blood).

What is the primary goal of discharge planning?

Answer: Ensure continuity of care and safe transition to the next level of care

Discharge planning begins at admission and aims to ensure the patient transitions safely to home, rehabilitation, or another care setting with appropriate support, education, medications, and follow-up — promoting continuity and preventing readmission.

A patient suddenly becomes unresponsive and has no pulse. What is the first action the nurse should take?

Answer: Call for help and activate the emergency response system

Per AHA BLS guidelines, a lone rescuer who finds an unresponsive pulseless adult should first call for help (activate the code system and get a defibrillator), then begin CPR. In a hospital setting, activating the team and getting a defibrillator is simultaneous.

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in a mechanically ventilated patient?

Answer: Elevate the head of bed 30–45 degrees and perform regular oral care with chlorhexidine

The ventilator bundle includes head-of-bed elevation (30–45°) to reduce aspiration risk and chlorhexidine oral care to reduce oral bacterial load. These are evidence-based VAP (ventilator-associated pneumonia) prevention measures.

What does a Glasgow Coma Scale score of 8 or below indicate?

Answer: Severe brain injury; airway protection required

GCS ≤8 defines a severe brain injury and indicates that the patient cannot protect their own airway. Intubation is generally indicated at GCS ≤8. The GCS scores eye, verbal, and motor responses, with a maximum of 15.