Inflammation and wound healing
After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care?
reposition every 2 hours
A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury?
rest,ice, compression, elevation
A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing?
custard
When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? 1. White blood cell (WBC) count of 8000/ìL; temperature of 101?5? F 2. White blood cell (WBC) count of 4000/ìL; temperature of 100?5? F 3. White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F 4. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8?5? F
3
a nurse is teaching a patient how to promote healing following abdominal surgery. what should be included in the teaching? 1. take the antibiotic until the wound feels better 2. take analgesic every day to promote adequate rest for healing 3. be sure to wash hands after changing the dressing to avoid infection 4. take in more fluid, protein, and vitamins C, B, and A to faciliate healing 5. notify HCP of redness, swelling, and increased drainage
3, 4
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? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankle's range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.
a
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's 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
a
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. which action is 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.
b
After receiving a change-of-shift report, which patient should 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 has been receiving chemotherapy and has a temperature of 102° F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change
c
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? a. Stage I b. Stage II c. Stage III d. Stage IV
c
a patient with a systemic bacterial infection feels cold and has a shaking chill. which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure
c
a patient's 4 by 3-cm leg wound has 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? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)
c
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? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. 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
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? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.
d
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted 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
d
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? a. Blood glucose 136 mg/dL b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm
d
The nurse will perform which action when doing a wet-to-dry dressing change on a patient with a stage III pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
d
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? 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.
d
Which patient is most at risk for the development of a pressure ulcer? 1. An older patient who is septic, bedridden, and incontinent 2. An obese woman with leukemia who is receiving chemotherapy 3. A middle-aged thin man in a halo cast after a motor vehicle accident 4. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis
1
to which patient should the nurse plan to administer round-the-clock antipyretic drugs? 1. 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F 2. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F 3. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F 4. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F
1
A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be?
Excess granulation tissue
The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse?
assess the patient and vaginal drainage
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment?
assessment of the patient's circulation distal to the location of the dressing
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 takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.
a
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? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound
a
a patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. how would the nurse document this wound? a. Red wound b. Yellow wound c. Full-thickness wound d. Stage III pressure ulcer
a
a patient with an open leg wound has a white blood cell count of 13,500/uL and a band count of 11%. what action should the nurse take first? 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.
a
a young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.18 F. which action by the nurse is the 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 patient's oral temperature again in 4 hours.
d
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? a. Change the patient's bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patient's position at least every 2 hours.
d
the nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas
d
A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state?
provide acetaminophen every 4 hours to maintain consistent blood levels
A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage?
purulent
An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient?
debride the nonviable, eschar tissue to allow healing
The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection?
general malaise and fatigue
a patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. after laboratory studies are performed, what does the nurse determine indicated the patient has a bacterial infection?
increased number of band neutrophils
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication?
intake and output
Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer?
maintain protein intake of at least 1.25 g/kg/day
The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse?
provide a light blanket
The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way?
systemic response
The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process?
the wound will be left open and heal from the edges inward
