Chapter 11: Inflammation and Wound Healing

The nurse should plan to use a wet-to-dry dressing for which patient?

A patient who has a wound with purulent drainage and dry brown areas

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?

Administer prescribed PRN hydrocodone 30 minutes before the change.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is *most* likely to detect early signs of infection in this patient?

Ask about feelings of fatigue or malaise.

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are *most* important for the nurse to teach the patient and family?

Change the patient's position every 1 to 2 hours.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate?

Check the patient's temperature again in 4 hours.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?

Document the assessment.

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

Elevate the ankle above heart level.

A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?

Hydrocolloid dressing

Which finding is most important for the nurse to communicate with the health care provider when caring for a patient who is receiving negative-pressure wound therapy?

Low serum albumin level

A patient who has diabetes is admitted for exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's *highest* priority?

Maintaining the patient's blood glucose within a normal range

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?

The new nurse cleans the ulcer with half-strength peroxide.

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take *first*?

Obtain cultures of the wound.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect *next*?

Rising body temperature

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is *most* important for the nurse to report to the health care provider?

Separation of the proximal wound edges

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?

Stage III

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?

The family member dries the wound using a hair dryer on a low setting.

After receiving a change-of-shift report, which patient should the nurse assess *first*?

The patient receiving chemotherapy who has a temperature of 102° F

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?

The patient takes oral hypoglycemic agents daily.

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?

Undermining