Chapter 12: Inflammation and Wound Healing
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 III
A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first?
Obtain wound cultures.
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 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
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 patient's position at least every 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). Which action by the nurse is most appropriate?
Check the patient's oral temperature again in 4 hours
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 by 1 cm
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.
After receiving a change-of-shift report, which patient should the nurse assess first?
The patient who has been receiving chemotherapy and has a temperature of 102° F
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)
The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
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
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
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?
Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change
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, how many total calories should the patient receive each day?
2140 calories
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 a space between each answer choice [A, B, C, D]).
Administer IV antibiotics. Administer acetaminophen (Tylenol). Sponge patient with cool water Perform wet-to-dry dressing change.
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?
Ask about fatigue or feelings of malaise.
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 most appropriate?
Document the assessment
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.
A patient's 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?
Hydrocolloid dressing (DuoDerm)
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?
Maintaining the patient's blood glucose within a normal range
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 set on a low setting.
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 a sterile dressing soaked in half-strength peroxide.