Chapter 13: Inflammation and Wound Healing My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 13: Inflammation and Wound Healing

Test Bank

MULTIPLE CHOICE

1. The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?

a.

Obtain wound cultures.

b.

Document the assessment.

c.

Notify the health care provider.

d.

Assess the wound every 2 hours.

ANS: B

The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention; the nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

DIF: Cognitive Level: Application REF: 192

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to

a.

obtain wound cultures.

b.

start antibiotic therapy.

c.

redress the wound with wet-to-dry dressings.

d.

continue to monitor the wound for purulent drainage.

ANS: A

The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

DIF: Cognitive Level: Application REF: 187 | 199 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

3. A patient with a systemic bacterial infection has goose pimples, feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for

a.

skin flushing.

b.

muscle cramps.

c.

rising body temperature.

d.

decreasing blood pressure.

ANS: C

The patients complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.

DIF: Cognitive Level: Application REF: 189

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate?

a.

Apply a cooling blanket.

b.

Notify the health care provider.

c.

Give the prescribed PRN aspirin (Ascriptin) 650 mg.

d.

Check the patients oral temperature again in 4 hours.

ANS: D

Mild to moderate temperature elevations (less than 103 F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patients health care provider or to use a cooling blanket for a moderate temperature elevation.

DIF: Cognitive Level: Application REF: 190

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A patients 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse use for wound care?

a.

Dry gauze dressing (Kerlix)

b.

Nonadherent dressing (Xeroform)

c.

Hydrocolloid dressing (DuoDerm)

d.

Transparent film dressing (Tegaderm)

ANS: C

The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

DIF: Cognitive Level: Application REF: 196-197

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a

a.

red wound.

b.

yellow wound.

c.

full-thickness wound.

d.

stage III pressure wound.

ANS: B

The description is consistent with a yellow wound. A stage III pressure wound would expose subcutaneous fat. A red wound would not have any creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description.

DIF: Cognitive Level: Comprehension REF: 193-194

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications?

a.

Monitor white blood cell count.

b.

Check the skin for areas of redness.

c.

Check the temperature every 2 hours.

d.

Ask about fatigue or feelings of malaise.

ANS: D

Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be just not feeling well.

DIF: Cognitive Level: Application REF: 190

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse will plan to use wet-to-dry dressings when providing care for a patient with a

a pressure ulcer with pink granulation tissue.

a.

surgical incision with pink, approximated edges.

b.

full-thickness burn filled with dry, black material.

c.

wound with purulent drainage and dry brown areas.

ANS: C

Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

DIF: Cognitive Level: Application REF: 198 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

9. A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage

a.

I.

b.

II.

c.

III.

d.

IV.

ANS: C

A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

DIF: Cognitive Level: Comprehension REF: 200

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

a.

change the patients bedding frequently.

b.

use a hydrocolloid dressing over the ulcer.

c.

record the size and appearance of the ulcer weekly.

d.

change the patients position at least every 2 hours.

ANS: D

The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions also may be included in family teaching, but the most important instruction is to change the patients position at least every 2 hours.

DIF: Cognitive Level: Application REF: 201-203

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patients stage III sacral pressure ulcer?

a.

Administer the ordered PRN oral opioid 30 minutes before the dressing change.

b.

Soak the old dressings with sterile saline a few minutes before removing them.

c.

Pour sterile saline onto the new dry dressings after the wound has been packed.

d.

Apply antimicrobial ointment before repacking the wound with moist dressings.

ANS: A

Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.

DIF: Cognitive Level: Application REF: 198 | 202

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. The charge nurse observes a new graduate performing a dressing change on a stage II left heel pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care?

a.

The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.

b.

The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer.

c.

The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline.

d.

The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

ANS: D

Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.

DIF: Cognitive Level: Application REF: 202 TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

13. A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate?

a.

Elevate the ankle above heart level.

b.

Remove the patients shoe and sock.

c.

Apply a warm moist pack to the ankle.

d.

Assess the ankles range of motion (ROM).

ANS: A

Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The soccer shoe does not need to be removed immediately and will help to compress the injury if it is left in place.

DIF: Cognitive Level: Application REF: 190-191

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?

a.

The patient states that the ulcers are very painful.

b.

The patient has had the heel ulcers for the last 6 months.

c.

The patient has several old incisions that have formed keloids.

d.

The patient takes corticosteroids daily for rheumatoid arthritis.

ANS: D

Chronic corticosteroid use will interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patients pain will be implemented, but pain does not impact directly on wound healing.

DIF: Cognitive Level: Application REF: 194

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first?

a.

The patient who has multiple black wounds on the feet and ankles.

b.

The newly admitted patient with a stage IV pressure ulcer on the coccyx.

c.

The patient who needs to be medicated with multiple analgesics before a scheduled dressing change.

d.

The patient who has been receiving immunosuppressant medications and has a temperature of 102 F.

ANS: D

Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient.

DIF: Cognitive Level: Analysis REF: 190

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

16. Which of these four patients should the medical-surgical unit charge nurse assign to an LPN team member?

a.

The patient who has increased tenderness and swelling around a leg wound.

b.

The patient who has just arrived after suturing of a full-thickness arm wound.

c.

The patient who needs teaching about home care for a draining abdominal wound.

d.

The patient who requires a hydrocolloid dressing change for a Stage III sacral ulcer.

ANS: D

LPN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the RN.

DIF: Cognitive Level: Application REF: 198

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

17. When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider?

a.

Blood glucose 136 mg/dl

b.

Oral temperature 101 F (38.3 C)

c.

Patient complaint of increased incisional pain

d.

New 5-cm separation of the proximal wound edges

ANS: D

Wound separation at a week postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings also will be reported, but do not require intervention as rapidly.

DIF: Cognitive Level: Application REF: 192

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

18. A diabetic patient is admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, the nurses highest priority will be

a.

maintaining the patients blood glucose within a normal range.

b.

ensuring that the patient has an adequate dietary protein intake.

c.

giving antipyretics to keep the temperature less than 102 F (38.9 C).

d.

redressing the surgical incision with a dry, sterile dressing twice daily.

ANS: A

Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102 F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.

DIF: Cognitive Level: Application REF: 194-195

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

COMPLETION

1. A patients temperature has been 101 F (38.3 C) for several days. The patients normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100 in body temperature, calculate the total calories the patient should receive each day. ____________________

ANS: 2140

DIF: Cognitive Level: Application REF: 190

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions are included in the patients plan of care. In which order should the nurse perform the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. Sponge patient with cool water.

b. Administer intravenous antibiotics.

c. Perform wet-to-dry dressing change.

d. Administer acetaminophen (Tylenol).

ANS:

B, D, A, C

The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.

DIF: Cognitive Level: Analysis REF: 190 | 199

OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

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