Chapter 11: Inflammation and Wound Healing

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, how many total calories should the patient receive each day?

2140 CALORIES

2. A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of 11%. What action should the nurse take first? Obtain wound cultures. Start antibiotic therapy. Redress the wound with wet-to-dry dressings. Continue to monitor the wound for purulent drainage.

A

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 most appropriate? Elevate the ankle above heart level. Apply a warm moist pack to the ankle. Assess the ankles range of motion (ROM). Assess whether the patient can bear weight on the affected ankle.

A

3. A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? Skin flushing Muscle cramps Rising body temperature Decreasing blood pressure

C

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? The patient takes insulin daily. The patient states that the ulcers are very painful. The patient has had the heel ulcers for the last 6 months. The patient has several old incisions that have formed keloids.

A

6. A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? Red wound Y ellow wound Full-thickness wound Stage III pressure ulcer

A

1. 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 a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics.b. Sponge patient with cool water.c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

A, D, B, C

1. The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? Obtain wound cultures. Document the assessment. Notify the health care provider. Assess the wound every 2 hours.

B

5. A patients 4 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? Dry gauze dressing (Kerlix) Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

C

16. The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? The patient who has increased tenderness and swelling around a leg wound The patient who was just admitted after suturing of a full-thickness arm wound The patient who needs teaching about home care for a draining abdominal wound The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

D

17. 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? Blood glucose 136 mg/dL Oral temperature 101 F (38.3 C) Patient complaint of increased incisional pain Separation of the proximal wound edges by 1 cm

D

15. After receiving a change-of-shift report, which patient should the nurse assess first? The patient who has multiple black wounds on the feet and ankles The newly admitted patient with a stage IV pressure ulcer on the coccyx The patient who has been receiving chemotherapy and has a temperature of 102 F The patient who needs to be medicated with multiple analgesics before a scheduled dressing change

C

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

C

10. A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? Change the patients bedding frequently. Use a hydrocolloid dressing over the ulcer. Record the size and appearance of the ulcer weekly . Change the patients position at least every 2 hours.

D

11. The nurse will perform which action when doing a wet-to-dry dressing change on a patients stage III sacral pressure ulcer? Soak the old dressings with sterile saline 30 minutes before removing them. Pour sterile saline onto the new dry dressings after the wound has been packed. Apply antimicrobial ointment before repacking the wound with moist dressings. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

D

12. 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 uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

D

20. After the home health nurse teaches a patients family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? The family member uses a lift sheet to reposition the patient. The family member uses clean tap water to clean the wound. The family member places contaminated dressings in a plastic grocery bag. The family member dries the wound using a hair dryer set on a low setting.

D

7. A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? Monitor white blood cell count. Check the skin for areas of redness. Check the temperature every 2 hours. Ask about fatigue or feelings of malaise.

D

8. The nurse should plan to use a wet-to-dry dressing for which patient? A patient who has a pressure ulcer with pink granulation tissue A patient who has a surgical incision with pink, approximated edges A patient who has a full-thickness burn filled with dry, black material A patient who has a wound with purulent drainage and dry brown areas

D

18. A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurses highest priority? Maintaining the patients blood glucose within a normal range Ensuring that the patient has an adequate dietary protein intake Giving antipyretics to keep the temperature less than 102 F (38.9 C) Redressing the surgical incision with a dry, sterile dressing twice daily

A

19. Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? Low serum albumin level Serosanguineous drainage Deep red and moist wound bed Cobblestone appearance of wound

A