Lewis Chapter 13

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 patient's 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

1. A patient's temperature has been 101° F (38.3° C) for several days. The patient's 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

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

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.

11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's 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.

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 patient's shoe and sock. c. Apply a warm moist pack to the ankle. d. Assess the ankle's 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.

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.

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.

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.

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.

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 patient's 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.

5. A patient's 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.

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 patient's pain will be implemented, but pain does not impact directly on wound healing.

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."

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.

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.

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 patient's 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 patient's health care provider or to use a cooling blanket for a moderate temperature elevation.

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.

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 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.

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 patient's position at least every 2 hours.

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. b. surgical incision with pink, approximated edges. c. full-thickness burn filled with dry, black material. d. wound with purulent drainage and dry brown areas.

ANS: D 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.

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.

Which actions aid in the prevention and early detection of infection in the client at risk? Select all that apply. A. Inspect the skin for coolness and pallor. B. Promote sufficient nutritional intake. C. Encourage fluid intake, as appropriate. D. Monitor the red blood cell (RBC) count. E. Obtain cultures as needed.

B, E

The 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Elevated mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate

a

Which information does the nurse include when teaching the client about antibiotic therapy for infection? A. Take all antibiotics as prescribed, unless side effects develop. B. Take antibiotics until symptoms subside, and then stop taking the drugs. C. Take antibiotics when symptoms of infection develop. D. Share antibiotics with family members who develop the same infection.

a

Which of the following strategies by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection? A. Provide a light blanket. B. Encourage a hot shower. C. Monitor temperature every hour. D. Turn up the thermostat in the patient's room.

a

Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is true? A. Antibiotics have been given to clients for conditions that do not require antibiotics. B. Microorganisms are more susceptible to antibiotics today than when they were given years ago. C. Additional precautions are taken, along with Standard Precautions, to prevent infection. D. Certain antibiotics are effective for specific infections only.

a

While in the hospital, the client has developed methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A. The nurse dons a gown to prevent contact with the client or with client-contaminated items. B. Assign the client to a private room with a negative airflow. C. The nurse dons a mask when working within 3 feet of the client. D. Have the client wear a surgical mask when being transported out of the room.

a

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which of the following parameters would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness

b

A patient with pneumonia is having a fever of over 103°F. The nurse should manage the patient's fever by: A. Administering aspirin on a scheduled basis around the clock. B. Providing acetaminophen every 4 hours to maintain consistent blood levels. C. Providing drug interventions if complementary and alternative therapies have failed. D. Administering acetaminophen when the patient's oral temperature exceeds 103.5° F.

b

The client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A. Taking the antibiotic before jogging 2 miles daily B. Taking the antibiotic most days C. Taking the antibiotic as prescribed D. Taking the antibiotic with a full glass of water

b

Which statement about handwashing, in accordance with recommendations by the Centers for Disease Control and Prevention (CDC), is true? A. If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C. Handwashing does not need to be done after resetting a client's IV pump. D. If the hands are not visibly soiled, washing the hands is not necessary.

b

Which statement by the nurse best educates the client with strep throat infection about infection control measures? A."It is better to use disposable paper plates and utensils than regular dishes for meals." B. "You and members of your family should each use separate toothbrushes." C. "You must remain indoors while recovering." D. "All members of your family need to be tested for strep."

b

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. Which of the following is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections C. Assessment of the patient's circulation distal to the location of the dressing D. Assessment of the range of motion of the ankle and the patient's activity tolerance

c

A pressure ulcer demonstrating full-thickness skin loss involving damage to subcutaneous tissue extending down to, but not through, the underlying fascia would be classified as which of the following stages? A. Stage I B. Stage II C. Stage III D. Stage IV

c

The nurse determines that the patient may be suffering from an acute bacterial infection based upon which of the following laboratory test results? A. Increased platelet count B. Increased blood urea nitrogen C. Increased number of band neutrophils D. Increased number of segmented myelocytes

c

The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A. Evaluating each other's handwashing technique B. Deciding which brand of handwashing soap to use C. Reinforcing the need for handwashing after caring for clients D. Determining which clients are most likely to infect other residents

c

When assessing a patient who is receiving cefazolin (Ancef) for treatment of a bacterial infection, the nurse would conclude that treatment has been effective based upon which of the following data? A. White blood cell (WBC) count 16,500/μl, temperature 98.8○ F B. White blood cell (WBC) count 8000/μl, temperature 101○ F C. White blood cell (WBC) count 8500/μl, temperature 98.4○ F D. White blood cell (WBC) count 4000/μl, temperature 100○ F

c

Which client is at greatest risk for developing an infection? A. 54-year-old man with hypertension B. 17-year-old woman with a fractured tibia in a cast C. 65-year-old woman who had coronary bypass surgery 4 days ago D. 71-year-old man in a nursing home

c

Which of these nurses would be assigned to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years B. An RN with experience in the operating room who transferred a month ago to the medical unit C. A float RN with 7 years of experience on the inpatient oncology unit D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago

c

Which statement about the transmission of hepatitis C is true? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors.

c

A priority problem of hyperpyrexia is identified by the long-term care RN who is caring for a client with a urinary tract infection. Which of these interventions is most appropriate to delegate to a nursing assistant? A. Monitor for improvement after antibiotic therapy is initiated. B. Teach the client the reason for taking antibiotics as prescribed. C. Administer acetaminophen (Tylenol) 650 mg orally for elevated temperature. D. Increase fluid intake by assisting the client to choose preferred beverages.

d

Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Decreased level of consciousness

d

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully washes hands that are visibly soiled B. Wears a mask and gloves when the client's body secretions or body fluids are likely to be handled C. Wears a mask with eye protection and performs proper handwashing D. Wears gloves when contact with body secretions or body fluids is expected

d