CH 11 EAQ Inflammation & Wound Healing

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

ANS: A Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is also 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.

Which treatment options would the nurse describe to a patient who is to undergo mechanical debridement of a wound? Select all that apply. a. Semi-occlusive dressing application b. Topical application of collagenase c. Surgical removal of eschar d. Wound irrigation e. Wet-to-dry dressing

ANS: D E There are four types of debridement: surgical, mechanical, autolytic, and enzymatic. Wet-to-dry dressings and wound irrigation are examples of mechanical debridement. Application of a semi-occlusive dressing (Duoderm) is an example of autolytic debridement. Topically applied collagenase (Santyl) provides enzymatic debridement. Surgical removal of eschar is considered surgical debridement.

The nurse is preparing to administer a medication that has the action to reduce capillary permeability. What medication will the nurse administer to the patient? a. Aspirin b. Piroxicam c. Ibuprofen d. Acetaminophen

ANS: A Aspirin is an antiinflammatory drug that reduces capillary permeability in the body. Ibuprofen is a nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis. Piroxicam is a nonsteroidal antiinflammatory drug that inhibits the synthesis of prostaglandin. Acetaminophen helps maintain thermoregulation by acting on the heat-regulating center in the hypothalamus.

A nurse is dressing a necrotic wound on a patient's leg with Aquaform hydrogel. What advantages does this hydrogel dressing have over other dressing material? Select all that apply. a. Rehydrates wound tissue b. Maintains a moist environment c. Donates moisture to dry wound d. Holds large amount of exudates e. Allows visualization of the wound

ANS: A B C The hydrogel dressing donates moisture to the wound and rehydrates the wound tissue. The dressing helps to keep the wound environment moist so that debridement occurs by a moisturizing effect. The hydrogel dressing does not allow visualization of the wound, because it is not transparent. The hydrogel dressing does not contain foam; therefore, it cannot hold large amounts of exudates.

Which action by the nurse would be most helpful in treating a patient who is experiencing chills related to 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

ANS: A Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient. Encouraging a hot shower, monitoring temperature every hour, and turning up the thermostat in the patient's room are not the most helpful actions in treating a patient with chills.

The nurse is educating a patient and family members about pressure ulcers. Which is the priority nursing action when conducting this educational session? a. Demonstrate correct positioning to prevent skin breakdown b. Emphasizing the importance of proper nutrition for wound healing c. Teaching the patient and family how to inspect the patient's skin daily e. Assessing the patient and family's financial resources for wound care

ANS: A Patient and caregiver education regarding pressure ulcers begins with prevention; therefore the nurse's first priority is to teach the patient and family the correct positioning for preventing the occurrence of skin breakdown. Next, the nurse should assess the patient and family's skill levels in conducting wound care, along with their financial resources to do so. The nurse should then teach the patient and family to inspect the skin each day. Finally, the nurse should educate the patient and family about the importance of proper nutrition as it pertains to wound healing.

A specimen is taken from a patient's wound and is found to contain white blood cells, microorganisms, debris, and liquefied dead cells when assessed. What type of exudate does the nurse determine this patient has? a. Purulent b. Catarrhal c. Hemorrhagic d. Serosanguineous

ANS: A Purulent exudate consists of white blood cells, microorganisms, debris, and liquefied dead cells. Purulent discharge is observed in furuncles, abscesses, and cellulitis. Catarrhal exudate contains mucus. Hemorrhagic exudate contains red blood cells. Serosanguineous exudate contains red blood cells and serous fluid.

A patient is being discharged from the health care facility after an abdominal cholecystectomy. What should the nurse teach the patient and the family about wound care? Select all that apply. a. Increase fluid intake. b. Consume a high-protein diet. c. Observe the wound for complications. d. Avoid B-complex vitamin supplements. e. Discontinue antibiotics when pain subsides. f. Follow aseptic procedures during dressing change.

ANS: A B C F The patient should increase fluid intake to replace fluid loss from perspiration, exudate formation, and increased metabolic rate. The patient should consume a diet high in protein, carbohydrate, and vitamins with moderate fat to promote healing. The nurse should teach the patient aseptic procedures to keep the wound free from infection. The nurse should also teach the patient to observe and notify the health care provider about any complications in the wound. The patient should take vitamin B supplements to prevent deficiency, which could disrupt metabolism of protein, fat, and carbohydrate. The nurse should inform the patient of the need to continue the drugs for the prescribed time to prevent occurrence of drug-resistant organisms.

A nurse is assessing the risks of patients for developing pressure ulcers. Which patients are at the highest risk for developing pressure ulcers? Select all that apply. a. A 65-year-old female patient with quadriplegia; nonambulatory b. A 49-year-old male patient with sepsis; responds in grunts; disoriented c. A 52-year-old male patient who had suffered myocardial ischemia; moderate ambulation d. A 58-year-old female patient with stroke and incontinence of urine and stool; ambulates with a wheelchair e. A 67-year-old male patient with a history of falls and current fractures of the right humerus and one rib

ANS: A B D Pressure develops in patients who are nonambulatory and who do not change their positions often. Patients who have quadriplegia, are disoriented, are nonambulatory, or have had a brain injury are at high risk of developing pressure ulcers. These patients cannot move by themselves and need help to change position. Therefore they are at high risk of developing pressure ulcers. The patient who had myocardial infarction has moderate ambulation and can change positions in bed, so the risk of pressure ulcers is low. Similarly, the patient with fractures of the right humerus and rib is ambulatory and is at low risk for pressure ulcer.

A nurse is caring for a patient who has developed gangrenous ulcers on the foot, making walking difficult. There is purulent drainage from the ulcer, and black adherent necrotic tissue can be observed. What should be included in the plan of care for the patient? Select all that apply. a. Hydrotherapy b. Topical debridement c. Transparent film dressing d. Gentle atraumatic cleansing e. Absorptive dressing covered with gauze

ANS: A B E Hydrotherapy will help to keep the wound moist, and an absorptive dressing will help absorb the purulent discharge. Because black adherent necrotic tissue can be seen, topical debridement needs to be done to remove the necrotic tissue and expose healing tissue. An absorptive dressing covered with gauze is also required to absorb the exudate. Transparent film dressings are used in dry and uninfected wounds or wounds with less drainage. Because this wound is infected and has purulent discharge, transparent film dressing cannot be used. Gentle atraumatic cleansing is required in freshly inflicted red wounds. Gentle cleansing will not remove the necrotic tissue present in this case.

A patient receiving long-term corticosteroid therapy for rheumatoid arthritis is admitted to the hospital with a wound of the left upper extremity. What should the nurse expect while assessing this patient? Select all that apply. a. The patient is at risk of hyperglycemia. b. The wound of this patient will heal slowly. c. There will be reduced bleeding from the wound. d. The patient is at a risk of developing bone infection. e. The symptom of fever may be blunted in this patient.

ANS: A B E Persistent hyperglycemia (steroid diabetes) can occur because of altered glucose metabolism. Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of patients receiving long-term corticosteroid therapy tend to heal slowly. Because of the depressed immune system, fever may be blunted in this patient. Corticosteroid therapy does not affect the risk of bleeding from the wound or the risk of bone infection.

he nurse is caring for a patient who has a healing abdominal wound. What factors does the nurse determine that could possibly cause a wound dehiscence? Select all that apply. a. Obesity b. Anemia c. Infection d. Hypertension e. Seroma formation

ANS: A C E Obesity, presence of infection, and seroma formation between the margins of the wound may increase the risk of wound dehiscence. People who are obese are at high risk for dehiscence because adipose tissue has less blood supply and may slow healing. Infection causes an inflammatory process. The granulation tissue formed may not be strong enough to withstand forces imposed on the wound. A pocket of fluid, seroma, formed between tissue layers, prevents the edges of the wound from coming together. Hypertension and anemia do not cause wound dehiscence.

The nurse is educating a patient with a wound that has been difficult to heal and who is scheduled for hyperbaric oxygen therapy. The patient asks, "How will this help when everything else hasn't?" What is the best response by the nurse? Select all that apply. a. "It kills anaerobic bacteria." b. "It prevents formation of new blood vessels." c. "It slows down formation of granulation tissue." d. "It increases the effectiveness of certain antibiotics." e. "It increases the killing power of white blood cells (WBCs)."

ANS: A D E Hyperbaric oxygen therapy involves delivering oxygen at increased atmospheric pressure. The therapy kills anaerobic bacteria in the wound, preventing further infection. It increases the killing power of WBCs and certain antibiotics. The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. Hyperbaric oxygen therapy accelerates formation of granulation tissue, which in turn accelerates the wound healing process.

A patient sustained multiple lacerations and wounds in a motor vehicle crash. Which food items should be encouraged to promote healing in the patient? Select all that apply. a. Guava b. Apple c. Banana d. Strawberry e. Kiwi fruits

ANS: A D E Vitamin C is a very important nutrient that helps in wound healing. Deficiency of vitamin C delays formation of collagen fibers and capillary development. The nurse should encourage the patient to eat guava, strawberries, and kiwi, because these fruits are rich in vitamin C. Apples and bananas are not rich sources of vitamin C.

A patient has a deep, red wound caused by trauma while playing football. What interventions should the nurse provide while dressing this moderate red wound? Select all that apply. a. Keep the wound moist. b. Perform wound irrigations. c. Keep the wound as dry as possible. d. Use transparent film to dress the wound. e. Use an adhesive semipermeable dressing to cover this wound.

ANS: A D E Keeping the wound moist is extremely important in a red wound. A moist environment helps in granulation and re-epithelialization. Transparent films and adhesive semipermeable dressings are permeable to oxygen and are used in red wounds. Airing out a wound is not recommended because it can dry the wound and prevent formation of granulation tissue. Wound irrigations are usually avoided because unnecessary manipulation can destroy the granulation tissue.

postoperative patient now is able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? a. Apple b. Custard c. Popsicle d. Potato chips

ANS: B Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. An apple, popsicle, or potato chips do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that also are needed for healing.

The nurse is caring for a patient who sustained full-thickness burns two weeks ago and determines that a weight loss of 16 lbs (7.27 kg) has occured. What adjustments should be made in the diet to ensure the metabolic requirements of the patient are being met? Select all that apply. a. Low-sodium diet b. High-protein intake c. Low-potassium diet d. High-carbohydrate intake e. Adequate intake of water

ANS: B D E The diet should be high in proteins to promote wound healing. High carbohydrate intake should be encouraged to help meet the high metabolic rate associated with burns. Fluid intake should be increased to compensate for the fluid loss. Sodium and potassium are restricted during the acute phase of a burn injury, not two weeks after the injury.

A registered nurse (RN) collaborates with a licensed practical nurse (LPN) to create a plan of care for the patient with a wound on the bottom of the heel. It is appropriate for the RN to assign which functions to the LPN? Select all that apply. a. Create a diet plan to support wound healing. b. Perform sterile dressing changes on the wound. c. Teach the patient about care of the wound at home. d. Develop a plan of care to accelerate wound healing. e. Collect and record data about the wound's appearance.

ANS: B E The role of the licensed practical nurse is to perform sterile dressing changes and collect and record data about the appearance of the wound. Making a diet plan, developing a plan of care, and teaching the patient require advanced nursing judgment and should be performed by the RN.

A nurse is preparing for the discharge of a patient with a pressure ulcer and includes the caregiver in the education. What should the nurse include in the home care instructions? a. Instruct the caregiver to reposition the patient every 20 minutes. b. Teach the caregiver to inspect the skin of the patient every 15 days. c. Teach the caregiver the "no touch" technique for changing the dressing. d. Instruct the caregiver to dispose of contaminated dressings along with other garbage.

ANS: C It is important to practice the "no touch" technique when changing the dressing to avoid wound contamination. Repositioning the patient every 20 minutes would be too frequent. However, the caregiver should reposition the patient at least every 2 hours. The skin of the patient should be inspected daily for pressure ulcers. The caregiver should be taught the proper way of disposing of contaminated dressings; they should not be disposed of with other garbage because they can spread infection.

The patient is admitted with a pressure ulcer with full-thickness skin loss involving damage to subcutaneous tissue. How should the nurse document it? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: C Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage II ulcers are partial-thickness with a red-pink wound bed. Stage IV ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle.

The nurse is assessing a surgical wound 3 days after the procedure and observes neatly approximated edges. What phase of wound healing does the nurse determine the patient is experiencing? a. Secondary intention b. Primary intention, granulation c. Primary intention, initial phase d. Primary intention, maturation phase

ANS: C The inflammatory phase is the initial phase of primary intention healing; this phase occurs three to five days after an injury. The wound edges are neatly approximated. Incision of edges and migration of epithelial cells are characteristics of the inflammatory phase. Secretion of collagen is a characteristic feature of the granulation phase. Remodeling of collagen is a characteristic feature of the maturation phase. Migration of fibroblasts is a characteristic feature of the granulation phase. Secondary intention involves wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss. These wounds may have edges that cannot be approximated.

An older adult patient is assessed to have a score of 16 on the Braden Scale. Based on this information, the nurse will plan which intervention for this patient? a. Massage the pressure points every shift. b. Apply moist gauze dressings over the bony prominences. c. Elevate the head of bed to 90 degrees when the patient is supine. d. Implement an every two hours turning schedule with skin assessment.

ANS: D A patient with a total Braden score of 16 or less is considered to be at risk for pressure ulcers. Pressure ulcers can be prevented by using an established risk assessment tool; repositioning frequently (every one to two hours); using devices to reduce pressure and shearing force (e.g., alternating pressure mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets); removing excessive moisture on the skin; avoiding massage over bony prominences; positioning with pillows; and assisting the patient in maintaining a healthy weight. Moist gauze dressings are appropriate for yellow pressure ulcers, not for patients who are assessed at risk for pressure ulcers. Elevating the head of the bed 90 degrees is not necessary in this instance.

The nurse is reviewing the medical reports of four patients. Which patient may show a blunted febrile response to infection? a. Patient A: The patient has rheumatoid arthritis and is being treated with piroxicam. b. Patient B: The patient has inflammation associated with asthma and is being treated with prednisone. c. Patient C: The patient has severe wound infection and is being treated with chlorhexidine d. Patient D: The patient has cancer and is being treated with becaplermin.

ANS: A A patient with rheumatoid arthritis who is being treated with a nonsteroidal antiinflammatory drug (such as piroxicam) (Patient A) may show a blunted febrile response to infection. Prednisone is a corticosteroid and is used to treat inflammation associated with asthma (Patient B); a decreased synthesis of lymphocytes is a side effect of the drug. Chlorhexidine is an antiseptic used to clean the wound; this drug may not result in blunted febrile response (Patient C). Becaplermin is not a nonsteroidal antiinflammatory drug and does not blunt febrile response to infection (Patient D).

The nurse is caring for a patient with diabetes who has developed a foot ulcer without necrotic tissue. Because the patient is at risk for delayed wound healing, what treatment will the nurse anticipate administering that will stimulate wound healing? a. Becaplermin b. Collagenase c. Surgical debridement d. Autolytic debridement

ANS: A Becaplermin, a recombinant human platelet-derived growth factor gel, actively stimulates wound healing. It is used to treat foot ulcers in patients with diabetes. Surgical debridement and collagenase are unnecessary without the presence of necrotic tissue. Since there is no eschar present, the use of autolytic debridement may destroy the healthy tissue.

The nurse is caring for a patient who has a pressure ulcer. The patient has a 20-year history of smoking. What education should the nurse provide to the patient regarding wound healing and smoking? a. It impedes blood flow to healing areas. b. It slows collagen synthesis by fibroblasts. c. It decreases the blood supply in fatty tissue. d. It decreases the supply of nutrients to the injured area.

ANS: A Cigarettes contain nicotine, which is a potent vasoconstrictor, and thus impedes blood flow to healing areas and delays wound healing. A decreased blood supply in fatty tissue is a consequence of obesity. Advanced age may result in slow collagen synthesis by fibroblasts. A decreased supply of nutrients to the injured area occurs due to inadequate blood supply.

The nurse is caring for a patient with a wound. The edges are approximated, and the nurse notes migration of epithelial cells. When documenting this patient's wound, which term should the nurse use to indicate the primary intention phase of healing? a. Initial b. Maturation c. Granulation d. Scar contraction

ANS: A During the initial phase of primary intention, there is an approximation of incision edges, a migration of epithelial cells, and the appearance of clots that serve as a meshwork for starting capillary growth; therefore the nurse should use this term when documenting the appearance of the wound. Granulation occurs when there is a migration of fibroblasts, secretion of collagen, abundance of capillary buds, and the wound is fragile. Maturation and scar contraction occur when there is a remodeling of collagen and strengthening of the scar.

The nurse is reviewing the laboratory report of a patient who has been admitted to the hospital for a stab wound in the abdomen. Which finding is likely to be seen in the report? a. Leukocytosis b. Albuminuria c. Polycythemia d. Thrombocytopenia

ANS: A Leukocytosis results from an increase in the release of WBCs as a result of inflammation as a response to the stab wound. Albuminuria is the presence of albumin in urine. Polycythemia is an increase in the RBC count. Thrombocytopenia is a relative decrease of platelets in the blood.

Which cells release growth factors that initiate the healing process? a. Platelets b. Monocytes c. Neutrophils d. Red blood cells

ANS: A Platelets release growth factors that initiate the healing process. Monocytes help clean the area before healing. Neutrophils play an important role in producing inflammatory response. Red blood cells do not release any growth factors that initiate the healing process.

The nurse is caring for a patient with multiple skin blisters over the chest and back after taking seizure medications. What type of exudate does the nurse anticipate documenting if the blisters rupture? a. Serous b. Fibrinous c. Hemorrhagic d. Serosanguineous

ANS: A Skin blisters result in an outpouring of fluid and produce serous exudate. Serous fluid exudate is generally seen in the early stages of inflammation. Fibrinous exudate is seen in surgical drain tubing. Hemorrhagic exudate is seen if a patient is bleeding after surgery. Serosanguineous exudate is seen in surgical drain fluid.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive 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 nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.

A patient is admitted to the acute care facility with a diagnosis of severe, acute appendicitis. What treatment option will the nurse prepare the patient for? a. An appendectomy b. Administration of antipyretics c. Administration of IV corticosteroids d. Intravenous (IV) administration of antibiotics

ANS: A Surgical removal is the best treatment for inflammation of the appendix to prevent further complications. Antipyretics are used to reduce fever that may be associated with appendicitis, but will not promote healing. Antimicrobials are used to kill bacteria that may be involved, but in a life-threatening situation, surgery is required. Corticosteroids reduce inflammation but cause immunosuppression, reducing the body's ability to fight infection.

What is the function of the complement system during an immune response? a. Cellular lysis b. Promoting clot formation c. Decrease in vascular permeability d. Cleaning the injured area before healing

ANS: A The complement system causes cell lysis by creating holes in the cell membranes, causing those cells to rupture. The complement system increases vascular permeability. Thromboxane promotes clot formation during healing. Macrophages clean the injured area before healing.

The nurse is administering a vitamin supplement to a patient with a surgical wound. What supplement will the nurse administer to the patient that will accelerate epithelialization? a. Vitamin A b. Vitamin C c. Vitamin D d. B-complex vitamins

ANS: A Vitamin A accelerates epithelialization by combining with the collagen shields of the skin. Vitamin C helps in the synthesis of collagen and new capillaries. Vitamin D facilitates calcium absorption. B-complex vitamins act as coenzymes.

The nurse is assessing a patient prior to applying a compression bandage. What are priority assessments the nurse must make before applying the bandage? Select all that apply. a. Distal pulses b. Capillary refill c. Serum protein levels d. Fluid and Electrolytes e. Partial thromboplastin time

ANS: A B Applying a compression bandage may compromise the patient's blood circulation. Therefore the nurse should assess the distal pulses to evaluate blood circulation before and after applying a compression bandage. The nurse should check capillary refill before and after applying a compression bandage to ensure adequate blood circulation. Serum protein levels should be monitored after performing negative-pressure wound therapy. Partial thromboplastin time should be checked after performing negative-pressure wound therapy. The patient's Fluid and Electrolytes should be checked after applying negative-pressure wound therapy because fluid and electrolyte loss may occur.

Which type of primary dressing would the nurse select for a patient whose wound has moderate to heavy exudate? Select all that apply. a. Foam dressing b. Alginate dressing c. Non-adherent dressing d. Hydrocolloid dressing e. Gauze dressing

ANS: A B Foam dressings and alginate dressings are best suited for moderate to heavy drainage or exudates. These dressings provide protection from infection and also can hold large amounts of exudates. Non-adherent dressings are used for minor wounds or as a secondary dressing. Hydrocolloid dressings are good for wounds with only light to moderate exudates. Gauze and nonwoven dressings are used for maintaining a moist wound surface or are used as secondary (cover) dressings, not as the primary dressing, for a heavily exudative wound and are not suitable for wounds that have drainage or exudates.

A nurse is caring for a patient who is receiving negative-pressure wound therapy. Which parameters should be monitored for a patient on negative-pressure wound therapy? Select all that apply. a. Platelet count b. Prothrombin time c. Serum creatinine level d. Partial prothrombin time e. Fasting blood glucose level

ANS: A B D Negative-pressure wound treatment creates negative pressure in the wound bed and pulls excess fluid from the wound, reduces bacterial load, and encourages blood flow to the wound bed. As a result, it is important to monitor the platelet count, prothrombin time, and partial prothrombin time in the patient. Serum creatinine level is related to kidney function and checking it may not be necessary in this case. Blood glucose levels do influence the wound-healing process but are not directly affected by negative-pressure wound therapy.

A patient is admitted with a chronic heel ulcer. What assessment findings would indicate systemic manifestations of inflammation? Select all that apply. a. Temperature 102.2°F b. Heart rate 116 beats/min c. Elevated serum protein levels d. Patient reports nausea and anorexia e. (WBC) count 8,000/μL with a shift to the right

ANS: A B D Systemic manifestations of inflammation include an increased WBC count with a shift to the left (not the right), malaise, nausea and anorexia, increased pulse and respiratory rate, and fever. The normal ranges are as follows: temperature 97-99 degrees; heart rate 60-11 beats/minute; WBC count 4,500-11,000 μL. Elevated serum protein levels do not indicate inflammation.

A patient is admitted to the hospital two hours following a suspected soft tissue injury to the ankle without external bleeding. What nursing actions are used to relieve the inflammation? Select all that apply. a. Provide cold application to the affected part. b. Immobilize the affected part and encourage rest. c. Make the patient lie down and keep the ankle below the level of heart. d. Apply a compression bandage to the ankle and check the distal pulse. e. Make the patient walk a little distance to increase circulation in the affected area.

ANS: A B D In cases of soft tissue injuries, RICE treatment (rest, ice, compression, and elevation) is given. The affected part is immobilized and given rest. Ice or cold is applied to reduce pain and inflammation. Hot applications can be given after 24 to 48 hours. The affected part is compressed with bandages to provide support and prevent edema. The affected part should be elevated above the heart level to prevent edema and pain. Making the patient walk would increase pain and discomfort, so it is not advisable.

A patient is on bed rest for several weeks. What areas should the nurse assess in order to intervene early to prevent complications from pressure? Select all that apply. a. Heel b. Neck c. Elbow d. Sacrum e. Scapular region

ANS: A D E A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. The heel and sacrum are the most common sites of pressure ulcers. Pressure ulcers also develop on the skin over the scapula bones. The neck and elbows are not at risk for pressure ulcers.

A nurse is developing a plan of care for a patient with a soft tissue injury and related inflammation as a result of a motor vehicle accident. Which nursing intervention should be included in the plan? a. Keep the injured extremity moving for proper blood circulation. b. Elevate the injured extremity above the level of the heart to reduce pain. c. Avoid compression bandages because they may compromise circulation. d. Use hot fomentation to increase the circulation at the inflamed site during initial trauma care.

ANS: B An injured extremity may become engorged with blood. Elevation of the injured extremity above the level of the heart helps to reduce pain associated with swelling by increasing the venous and lymphatic return. Compression helps to reduce vasodilation and edema. However, distal pulses should be assessed before and after a compression bandage is applied, to evaluate whether the extremity has compromised circulation. If the circulation is not compromised, a compression bandage can be used. The injured extremity should be immobilized and allowed to rest, because immobilization promotes healing by decreasing the metabolic needs of the patient. At the time of initial trauma, cold fomentation should be used to promote vasoconstriction and decrease pain, swelling, and congestion. Heat may be used 24 to 48 hours after injury to promote healing by increasing circulation at the inflamed site.

A patient with pneumonia has a fever of over 103° F. What nursing action is a priority to manage the patient's fever? a. Administer aspirin on a scheduled basis around the clock. b. Provide acetaminophen every four hours to maintain consistent blood levels. c. Administer acetaminophen when the patient's oral temperature exceeds 103.5° F. d. Provide drug interventions if complementary and alternative therapies have failed.

ANS: B Antipyretics should be given around the clock to prevent acute swings in temperature. Aspirin (ASA) would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. 103.5° F is already a high fever, and antipyretics should be given sooner. When treating fever, drug interventions normally are not withheld in lieu of complementary therapies.

Which term refers to the directional migration of white blood cells to the site of a cellular injury? a. Cell lysis b. Chemotaxis c. Shift to the left d. Chemical mediation

ANS: B Chemotaxis refers to the directional migration of white blood cells to an injury site. Cell lysis refers to cell rupture, leading to cell death. Chemical mediation describes the mediation of the inflammatory response by a variety of chemical mediators. A shift to the left refers to the presence of band neutrophils, which are an early sign of inflammation.

Which type of exudate does the nurse likely observe in a patient who has diffuse inflammation of the connective tissue? a. Serous b. Purulent c. Fibrinous d. Hemorrhagic

ANS: B Diffuse inflammation in connective tissue is called cellulitis; this condition produces purulent exudate. Serous exudate is observed in pleural effusion. Fibrinous exudate is seen in surgical drain tubing. Hemorrhagic exudate is seen in hematoma.

When developing a care plan for reducing the risk of pressure ulcers in a patient with multiple risk factors, the nurse includes which intervention as the priority method to reduce this risk? a. Encourage increased intake of juices. b. Reposition the patient every two hours. c. Massage bony prominences once per shift. d. Clean the skin area once per day with hydrogen peroxide.

ANS: B The best intervention to reduce the risk of pressure ulcers is to reposition the patient every two hours. Massage is contraindicated if fragile skin is present. Although juices may contain nutrients that support healing, they do not reduce pressure ulcer risk. Hydrogen peroxide is cytotoxic, so its use is discouraged.

The nurse is caring for a patient with a wound classified as a "black wound". What treatment will the nurse administer to this patient? a. Apply hydrocolloid dressing. b. Debride nonviable, eschar tissue. c. Apply adhesive semipermeable dressing. d. Clean gently to prevent damage to tissue.

ANS: B The immediate treatment of a black wound is debridement of the nonviable, eschar tissue. Adhesive semipermeable dressings are used to treat red wounds; they keep the wound surface clean and slightly moist to promote epithelialization. Yellow wounds must be cleansed gently to prevent damage to newly formed tissue and covered with hydrocolloid dressing to absorb exudate and clean the wound surface.

The nurse is preparing a patient for discharge after an appendectomy. The patient asks why they are unable to lift anything heavy for 6 weeks. What is the best response by the nurse? a. "The wound is in the repair phase of healing during this period." b. "The wound is in the maturation phase of healing during this period." c. "The wound is in the granulation phase of healing during this period." d. "The wound is in the regeneration phase of healing during this period."

ANS: B The maturation phase begins with scar contraction. It begins after seven days and may continue for several months or years. The fibroblasts disappear during this period, and the wound becomes stronger. Lifting heavy weights may tear the wound apart because of the pressure exerted. The repair, granulation, and regeneration phases occur before the maturation phase.

A patient is to be discharged home with negative-pressure wound therapy in place. There are no health care members in the family, and the daughter will be caring for the patient. What emotion should the nurse most anticipate addressing in the discharge teaching? a. Anger b. Anxiety c. Sadness d. Happiness

ANS: B The patient's daughter may be experiencing anxiety about her ability to perform wound care with negative-pressure wound therapy in place since she is not a healthcare provider. There is not enough information in this scenario to determine if this caregiver is experiencing anger, sadness, or happiness.

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 has had the heel ulcers for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the ulcers are very painful. d. The patient has several incisions that formed keloids.

ANS: B The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the past 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 directly affect wound healing.

A patient with a surgical wound visits the wound care center. The nurse notes that the wound is pink and vascular with numerous red granules. In what stage of healing is the wound? a. Initial phase b. Granulation phase c. Maturation phase d. Scar contraction

ANS: B The wound is in the granulation phase of primary intention healing. Primary intention healing takes place when wound margins are neatly approximated, as in a surgical incision. In the initial three to five days, fibrin clot serves as mesh work for future capillary growth and migration of epithelial cells. Scar contraction occurs during the maturation phase. In contrast to granulation tissue, a mature scar is virtually avascular and pale. The scar may be more painful at this phase than in the granulation phase.

A nurse is examining an intravenous site and confirms that inflammation is present at the site. What signs of inflammation may be present in the patient? Select all that apply. a. Ulcers at the site b. Swelling of the site c. Black discoloration d. Redness at the site e. Reports of pain at the site

ANS: B D E Signs of inflammation are pain, swelling, and redness. Pain is caused by the change in pH, nerve stimulation by chemicals, and pressure from fluid exudate. Swelling is caused by fluid shift to interstitial spaces and accumulation of fluid exudate. Redness is a result of hyperemia from vasodilation. Blackish discoloration and ulcers are not indicative of inflammation.

A patient asks the nurse what the surgeon meant by "the wound will be allowed to heal by secondary intention." What is the best response by the nurse? a. "The wound will be stapled together until it heals." b. "The healing will contract the area to close the wound." c. "The wound will be left open and heal from the edges inward." d. "The wound will be sutured after the current infection is controlled."

ANS: C With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.

A patient admitted for treatment of a large pressure ulcer on the right heel asks the nurse about new inflammation in the subcutaneous tissue. What term best describes the current issue the patient is experiencing? a. Sepsis b. Keloid c. Fistula d. Cellulitis

ANS: D Cellulitis can occur due to untreated pressure ulcers and involves the spreading of inflammation to the subcutaneous (connective) tissue. Sepsis occurs when an infection spreads to the bloodstream. A keloid is a permanent protrusion of scar tissue beyond the edges of the wound or injury. Fistulas are abnormal passages that may occur secondary to a wound.

The nurse pays close attention to which most common site for pressure ulcers when assessing the patient? a. Heels b. Ankles c. Elbows d. Sacrum

ANS: D Pressure ulcers generally occur over bony prominences; the sacrum is the most common site, followed by the heels. Elbows and ankles are less susceptible to pressure ulcers.

Which type of inflammatory exudate results from the rupture or necrosis of blood vessel walls? a. Serous b. Purulent c. Fibrinous d. Hemorrhagic

ANS: D The products of inflammation are known as inflammatory exudates. Exudates may ooze from the cuts or areas of inflammation. Hemorrhagic exudates result from rupture or necrosis of blood vessel walls during events such as hematoma, bleeding after surgery, or tissue trauma. Serous exudates result from an outpouring of fluid, seen in early stages of inflammation. Purulent exudates are associated with a preponderance of escaped leukocytes. Fibrinous exudates are formed by the action of fibrin ferment acting upon fibrinogen or fibrin-forming substances in the presence of calcium salts.

A patient has sustained an injury, but has no signs or symptoms of inflammation at the site of injury. Which laboratory finding does the nurse correlate with this finding? a. Zinc deficiency b. Protein deficiency c. Decreased red blood cell count d. Decreased white blood cell count

ANS: D White blood cells play an important role in the body's defense, and they facilitate the response to inflammation. A decreased white blood cell count causes neutropenia; a neutropenic patient is unable to mount an inflammatory response. Zinc deficiency impairs epithelialization in the wound-healing process. Protein deficiency decreases the supply of amino acids for tissue repair. Decreased red blood cell count causes anemia.

The nurse assesses a patient with an infiltrated intravenous (IV) site and observes rubor around the insertion site. What does the nurse determine has occurred related to the infiltration? a. Vasodilation b. Change in pH c. Shifting of fluid to interstitial spaces d. Increased metabolism at the inflammatory site

ANS: A Inflammation causes a release of inflammatory mediators, which results in vasodilation, hyperemia, and increased capillary permeability. Vasodilation causes redness, or rubor, at the inflammatory site. A change in pH releases prostaglandins, causing dolor (pain) at the injury site. A shifting of fluid to interstitial spaces causes swelling. Increased metabolism at the inflammatory site results in calor.

A nurse is caring for a patient who has an infected postoperative abdominal wound that is open and being treated with wet-to-dry sterile saline dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Primary intention c. Secondary intention d. Remodeling of tissues

ANS: A Tertiary intention healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. This occurs when a contaminated wound is left open and sutured closed after the infection is controlled. It also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Tertiary intention usually results in a larger and deeper scar than primary or secondary intention. Primary intention healing takes place when wound margins are approximated neatly, as in a surgical incision or a paper cut. A continuum of processes is associated with primary healing. These processes include three phases (initial phase, granulation phase, maturation phase) and scar contraction. The process of healing by secondary intention is essentially the same as healing by primary intention. The major differences are the greater defect and the gaping wound edges. Healing and granulation take place from the edges inward and from the bottom of the wound upward until the defect is filled. There is more granulation tissue, and the result is a much larger scar. Remodeling of tissues is an incorrect response.

After the unlicensed assistive personnel (UAP) bathed the patient, the UAP then told the registered nurse (RN) about a reddened area on the patient's coccyx. After assessing the area, what should the nurse have the UAP do for the patient? a. Reposition every two hours b. Measure the size of the reddened area c. Massage the area to increase blood flow d. Evaluate the area later to see if it is better

ANS: A The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that led to pressure ulcers. This would include eliminating pressure on the reddened area by repositioning every two hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

A nurse has assessed and planned care for patients in a unit. Which patient care tasks could be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. a. Perform dressing changes for chronic wounds using clean technique. b. Report changes in wound appearance or drainage to the registered nurse. c. Empty wound drainage containers and document drainage amount on the intake and output record. d. Plan nursing actions to assist with wound healing, including wound care and positioning. e. Provide teaching to patients and caregivers about care of wounds and prevention of pressure ulcers.

ANS: A B C Performing changes of dressing for chronic wounds using clean technique requires basic knowledge of the technique and can be delegated to the UAP. Reporting changes in wound appearance or drainage does not require nursing judgment and can be delegated to the UAP. Emptying wound drainage containers and documenting drainage on the intake and output record is a simple and repetitive task. It does not require specialized training and therefore can be delegated to the UAP. Providing teaching to patients and caregivers about home wound care and prevention of pressure ulcers requires understanding of the nursing process. These activities cannot be delegated to the UAP. Planning nursing actions to assist with wound healing, including wound care, and positioning requires nursing assessment, which cannot be delegated.

A nurse is caring for a patient who has a deep wound that has malodorous exudate. Which technique should the nurse use to collect a culture and sensitivity for analysis? Select all that apply. a. Wound exudate swab b. Swab using Z-technique c. Sample by tissue punch biopsy d. Swab using Levine's technique e. Tissue sample using needle aspiration

ANS: A B D Cultures can be obtained by needle aspiration, tissue culture, or swab technique. Concurrent swab specimens are obtained from wounds using wound exudates, Z-technique, and Levine's technique. A wound exudate swab is collected from the exudates before the wound is cleaned. In the Z-technique, the nurse rotates a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. In Levine's technique, the nurse rotates a culture swab over a cleansed 1-cm 2 area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers. A health care provider will obtain needle and tissue punch biopsy samples. As a nurse, you can obtain cultures using the swab technique.

The nurse is discussing the beneficial aspects of fever with a group of senior citizens. Which beneficial aspects of fever would the nurse include in the discussion? Select all that apply. a. Increased proliferation of T cells b. Increased release of epinephrine c. Enhancement of interferon activity d. Increased killing of microorganisms e. Impairment of the temperature control center

ANS: A C D Fever has several beneficial outcomes, including increased killing of microorganisms, increased proliferation of T cells, and enhancement of interferon activity. The increased release of epinephrine increases the metabolic rate and is involved in the development of fever. When a fever becomes too high, the temperature control center is impaired.

A nursing professor, teaching about cellular response after tissue injury, asks a nursing student about the role of neutrophils. What student response would indicate to the professor that the student understands the information? a. Neutrophils are the last to arrive at the injury site. b. Neutrophils phagocytize bacteria and damaged cells. c. Neutrophils are primarily involved in humoral immunity. d. Neutrophils transform into macrophages after entering the tissue spaces.

ANS: B Neutrophils are responsible for phagocytosis of bacteria and damaged cells at the site of injury. They are therefore first to arrive at the site. Lymphocytes, not neutrophils, are responsible for humoral immunity. Monocytes, not neutrophils, transform into macrophages after entering the tissue spaces.

The nurse is orienting a new nurse in the long-term care facility to the policy of prevention of complications related to the older adult and pressure ulcers. What should the nurse include regarding the assessment of pressure ulcers? Select all that apply. a. In home care, reassess patients at every visit. b. In acute care, ask patients if they can feel pain on any skin area. c. In acute care, reassess patients for pressure ulcers every 24 hours. d. In long-term care, reassess patients daily after the initial period is over. e. In long-term care, reassess the patient weekly for the first 4 weeks after admission.

ANS: A C E In acute care, patients should be reassessed for pressure ulcers every 24 hours because the patients are at high risk due to their disease condition and lack of mobility. In long-term care, reassess residents weekly for the first four weeks after admission and then at least monthly or quarterly. The patient may be mobile and able to take care of himself or herself; therefore, a weekly assessment is sufficient. In home care, reassess patients at every nurse visit because the patient may not be able to locate pain on the skin area caused by pressure ulcers.

A nurse is caring for a patient who is undernourished and sustained a trauma to the chest. How should the nurse plan the diet of the patient to ensure proper nutrition for adequate wound healing? Select all that apply. a. Increase the protein intake to promote synthesis of collagen. b. Limit fluid intake because it may result in increased exudate. c. Increase the intake of vitamin D to promote capillary synthesis. d. Increase the intake of vitamin A because it helps in epithelialization. e. Include a moderate amount of fats to help in synthesis of fatty acids.

ANS: A D E Increasing the amount of protein in the diet will help to increase the synthesis of collagen, leukocytes, and fibroblasts, all of which are necessary for healing. Vitamin A helps in epithelialization, so its intake should be increased. Including a moderate amount of fats will help healing because the fats help in the synthesis of fatty acids, which are part of the cell membrane. Fluid intake should not be limited, but rather should be increased because it helps replace the fluid that is lost from perspiration and exudate formation. Vitamin C, not vitamin D, is responsible for capillary synthesis.

A patient with a major wound is admitted to the hospital. When assessing this patient, what does the nurse identify as factors that may result in delayed healing of the wound? Select all that apply. a. The patient is obese. b. The patient has hypertension. c, The patient suffers from hyperlipidemia. d. The patient suffers from diabetes mellitus. e. The patient was on corticosteroid medications for a long time.

ANS: A D E Obesity decreases blood supply to the wound, causing delayed wound healing. Diabetes mellitus decreases collagen synthesis, retards early capillary growth, impairs phagocytosis, and reduces the supply of oxygen and nutrients secondary to vascular disease. Corticosteroid drugs impair phagocytosis by white blood cells, inhibit fibroblast proliferation and function, depress formation of granulation tissue, and inhibit wound contraction. Hypertension and hyperlipidemia do not have direct effects on wound healing.

The nurse is assessing the effectiveness of the administration of cefazolin for treatment of a bacterial infection. What outcome does the nurse determine demonstrates effectiveness of the medication regimen? a. WBC count 4000/μL, temperature 101° F b. WBC count 8500/μL, temperature 98.4° F c. WBC count 16,500/μL, temperature 98.8° F d. White blood cell (WBC) count 8000/μL, temperature 101° F

ANS: B A WBC count of 8500/μL and a temperature of 98.4° F are within the normal range. A normal WBC is 4000 to 11,000/μL. An elevated WBC count and elevated temperature are indicators of infection.

The nurse is preparing to perform a dressing change for a wound that is irregularly shaped and draining. What type of dressing should the nurse apply that forms a nonsticky gel? a. Foam b. Alginate c. Hydrogel d. Semipermeable transparent film

ANS: B Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregularly shaped wounds and generally require a secondary dressing. Foams are sheets that hold large amounts of exudates and mostly require gauze wrapping. Hydrogels donate moisture to a dry wound and maintain a moist environment that rehydrates wound tissue. Semipermeable transparent films allow visualization of the wound and are minimally absorbent.

A patient is prescribed acetaminophen 650 mg per rectum every six hours as needed for fever greater than 102° F. Which parameter 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

ANS: B Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness also will be monitored as with all patients, but intake and output are the priority for this patient.

A nurse is caring for an older adult asthmatic patient who underwent a hernia repair six hours previously. The temperature of the patient is 103.2 oF, the pulse rate is 99/min, and the blood pressure is 100/70 mm Hg. What would be the most effective nursing intervention? a. Maintain oxygen therapy. b. Administer antipyretic drugs routinely. c. Provide sponge baths to lower the temperature. d. Provide cooling blankets to lower the temperature.

ANS: B Because the patient is an older adult and has pulmonary disease, use of antipyretic drugs should be considered to lower the temperature to a particular set point. Many older adult patients are unable to tolerate higher core temperatures because of compromised immunity. Providing oxygen would help maintain oxygen saturation, but would not contribute to lowering the patient's temperature. Once the temperature has been lowered, sponge baths and a cooling blanket can be used to increase evaporative heat loss.

A patient who had abdominal surgery last week reports that the wound is now draining thick, white material and smells bad. After assessing the wound, how should the nurse document the drainage? a. Serous b. Purulent c. Fibrinous d. Catarrhal

ANS: B Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear, or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

An older adult patient is being cared for at home by the family. A pressure ulcer on the right trochantor area measures 1 × 2 × 0.2 cm in depth, with a red-pink wound bed without slough. Which stage would the home health nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: B Characteristics of a stage II ulcer include partial-thickness loss of dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough. Stage II ulcers also may manifest an intact or open/ruptured serum-filled blister. Characteristics of stage I ulcers include intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Characteristics of stage III ulcers include full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure depth of tissue loss. May include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomic location. Characteristics of stage IV ulcers include full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Depth of pressure ulcer varies by anatomic location. Ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

A patient is admitted with a diagnosis of osteomyelitis and exhibits malaise but no other manifestations of inflammation. Which drug therapy prescription does the nurse determine may be causing this condition? a. Salicylates b. Corticosteroids c. Vitamin D supplements d. Potassium supplements

ANS: B Corticosteroids are used to treat osteomyelitis. This drug suppresses immunity and masks classic manifestations of inflammation; thus a patient would present malaise. Salicylates are used to lower excessive body temperature and do not interfere with the immune mechanism. Potassium can strengthen the functions of the immune system. Vitamin D supplements facilitate calcium absorption.

During the assessment of a patient with an abdominal incision, the nurse notes the wound edges have separated, and the intestines are close to the surface. Which term should the nurse use when documenting this data in the medical record? a. Adhesion b. Evisceration c. Keloid formation d. Fistula formation

ANS: B Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound; therefore the nurse would use this term when documenting the patient's assessment data. Adhesions are bands of scar tissue that form between or around organs (such as the lungs or abdominal organs). A keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may form tumor-like masses of scar tissue. A fistula formation is an abnormal passage between organs or a hollow organ and skin (such as abdominal or perianal fistula).

The nurse is completing discharge teaching for a patient being released from the emergency department after evaluation of an ankle sprain. The nurse is teaching the patient about the rest, ice, compression, and elevation (RICE) approach to dealing with soft tissue injuries. Using RICE, when should the nurse instruct the patient to use heat? a. Immediately b. After 24 to 48 hours c. After 48 to 72 hours d. After the inflammation has begun to subside

ANS: B Heat should be used after 24 to 48 hours (after cold application) to increase circulation to the inflamed site. Cold is used immediately to promote vasoconstriction and decrease swelling, pain, and congestion at the site. The patient does not need to wait 48 to 72 hours or until the inflammation has begun to subside.

The nurse is assessing a pressure ulcer on a newly admitted patient and needs to record images of the wound at the various stages of healing using digital photography to monitor progress. What precautions should the nurse take when obtaining images of the wound? a. Use a flash for a clearer image. b. Position the patient the same way for each image. c. Use shiny underpads as a background for the wound to enhance the effect. d. Take the image from a different angle each time to cover all the sides of the wound.

ANS: B If the patient is positioned in the same way for each image, the angle in which the photo is taken will not change; this will help record the wound progression correctly. It is important to avoid flash whenever possible because it may reflect off the wound and affect clarity. The wound should be shown on a solid background, not on shiny underpads, for clearer images. Taking the image from different angles each time would make it more difficult to accurately monitor wound progression.

While reviewing a patient's laboratory reports, the nurse finds Mycobacterium strains in the patient's sputum. Which physiologic change does the nurse expect in this patient? a. Acute inflammation b. Granuloma formation c. Ivory to yellow-green exudate d. Tissue damage by complement activation

ANS: B In tuberculosis, the Mycobacterium bacillus is walled off, and the macrophages accumulate and fuse to form a multinucleated giant cell that engulfs the bacterial particle . This giant cell is encapsulated by collagen and forms granuloma. Tuberculosis causes chronic inflammation. Ivory to yellow-green exudate indicates infection, but is not seen in tuberculosis. Tissue damage by complement activation can occur in rheumatoid arthritis.

Which cells arrive first at the site of injury during the inflammatory response? a. Monocytes b. Neutrophils c. Lymphocytes d. Macrophages

ANS: B Inflammatory response is a sequential reaction to cell injury. Neutrophils are the first leukocytes to arrive at the injury site. They usually reach the site of injury within 6 to 12 hours. They engulf bacteria, other foreign material, and damaged cells. Monocytes are the second type of phagocytic cells that migrate from circulating blood. They usually arrive at the site within 3 to 7 days after the onset of inflammation. Lymphocytes arrive later at the site of injury. Their primary role is related to humoral and cell-mediated immunity. On entering the tissue spaces, monocytes transform into macrophages. Together with the tissue macrophages, these macrophages assist in phagocytosis of the inflammatory debris.

A nurse caring for a patient with an ankle injury observes erythema and edema along with serous fluid at the site of injury. What stage of the inflammatory response is the patient exhibiting? a. Healing b. Cellular response c. Vascular response d. Formation of exudate

ANS: C The patient is exhibiting vascular response. The serous fluid is a result of the outpouring of fluid, seen in the early stages of inflammation. During cellular response, neutrophils and monocytes move from vascular circulation to the site of injury, and the site becomes purulent. The nature and quantity of exudate formation prior to healing depend on the severity of injury. When the wound heals, there are no signs of inflammation.

A nursing student is learning about inflammation and wound healing. Which statement describing the process of wound healing conveys that the nursing student understands the process? a. "Regeneration is more complex than the process of repair." b. "Tertiary intention healing results in a larger and deeper scar." c. "Delayed closure with sutures is a secondary intention healing." d. "Primary intention healing takes place when wound margins are irregular."

ANS: B Tertiary intention healing is a delayed suturing of a wound after the infection has been controlled. Because it is associated with delayed healing, the scar is larger and deeper than the scar that results from primary and secondary intention healing. The process of repair is more complex than the process of regeneration because repair occurs by primary, secondary, and tertiary intention. Secondary intention healing is the healing of wounds whose edges cannot be approximated. Delayed closure with sutures is a form of tertiary intention healing. Primary healing takes place when wound margins are clear and concise.

The patient has inflammation and reports malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? a. Local response b. Systemic response c. Infectious response d. Acute inflammatory response

ANS: B The systemic response to inflammation includes the manifestations of a shift to the left in the white blood cell (WBC) count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in two to three weeks and usually leaves no residual damage.

A nurse is examining the pressure ulcer of a patient and observes that subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. Slough is present, and there is tunneling of the ulcer. From this observation, what stage of the ulcer should the nurse record in the patient's medical record? a. Stage II b. Stage III c. Stage IV d. Unstageable

ANS: B There are four stages of pressure ulcers. In stage III, subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. The slough is present, and there is tunneling of the ulcer. In stage II, the wound bed appears red to pink and the slough is absent. In stage IV, bone, muscle, and tendon are exposed. In an unstageable ulcer, the base of the ulcer is covered with slough and the true depth of the ulcer cannot be determined unless the slough is removed.

To prevent complications, what turning schedule should the nurse implement for a patient who spends most of the day in bed? a. Repositioning the patient every half hour b. Repositioning the patient every one to two hours c. Keeping the patient supine as much as possible d. Turning the patient from one side to the other once every four to eight hours

ANS: B Turning and repositioning the patient every one to two hours will keep pressure areas from developing and help prevent other pulmonary and vascular complications. Repositioning the patient every half hour is unrealistic. Keeping the patient supine as much as possible does not support the turning schedule. Turning the patient from one side to the other every four to eight hours is too much time between turning and repositioning.

The nurse has an order for mechanical debridement of a patient's pressure ulcer. Which activity will the nurse plan? a. Surgical removal of eschar b. Application of wet-to-dry dressings c. Application of semiocclusive or occlusive dressings d. Administration of topical drugs to dissolve necrotic tissue

ANS: B Two methods are used for mechanical debridement: wet-to-dry dressings and wound irrigation. Surgical removal of eschar is referred to as surgical debridement. Semiocclusive and occlusive dressings are a method of autolytic debridement. The use of topical drugs to dissolve necrotic tissue is referred to as enzymatic debridement.

The nurse is providing care to a patient who is experiencing delayed healing of a surgical wound. Which question assesses the patient for the presence of nutritional deficiencies? a. "Do you smoke cigarettes?" b. "How much protein do you eat with each meal?" c. "Do you monitor your blood glucose levels on a daily basis?" d. "Are you currently taking a glucocorticoid drug for inflammation?"

ANS: B When assessing for nutritional deficiencies related to delayed wound healing, the nurse should ask the patient about vitamin C, protein, and zinc consumption. Although smoking, poorly controlled blood glucose levels, and taking prescribed glucocorticoids can all delay wound healing, these questions are not appropriate when assessing the patient specifically for nutritional deficiencies.

A patient sustained severe injuries following a motor vehicle accident and is recovering. What nutritional instructions should the nurse give to the patient? Select all that apply. a. Include foods rich in sodium. b. Include foods rich in vitamin C. c. Include foods rich in vitamin B 12. d. Consume adequate quantities of water. e. Include water mixed with sugar and salt.

ANS: B C D Vitamin C and vitamin B 12 are important for wound healing. An adequate intake of water is extremely important for all body functions. Sodium is not a prime nutrient for wound healing. Having water mixed with sugar and salt is not important for healing.

A bedridden patient has pressure ulcers. What are the priority interventions that a nurse should take while cleaning these ulcers? Select all that apply. a. Use hydrogen peroxide to clean the wound. b. Use noncytotoxic solution to clean the wound. c. After cleaning the wound, cover it with gauze dressing. d. Irrigate the wound using a 30-mL syringe and 19-gauge needles. e. Irrigate the wound by pouring the solution over the wound and dabbing it.

ANS: B C D When cleaning pressure ulcers, use noncytotoxic solutions that do not kill or damage cells, especially fibroblasts. After cleaning, the wound should be covered with gauze dressing to protect it from infection. It is also important to use enough pressure to adequately clean the pressure ulcer without causing trauma or damage to the wound. To obtain this pressure, use a 30-mL syringe and a 19-gauge needle. Hydrogen peroxide is cytotoxic and therefore should not be used to clean pressure ulcers. The wound cannot be adequately cleansed if the solution is just poured and dabbed.

Which systemic clinical manifestations does the nurse most anticipate finding in a patient who has inflammation at an injury site? Select all that apply. a. Body temperature of 98° F b. Body temperature of 101° F c. Pulse rate of 120 beats/minute d. White blood cell count of 13,000/µL e. Respiratory rate of 10 breaths/minute

ANS: B C D The clinical manifestations of inflammation at the injury site are increased pulse and respiratory rate, increased white blood cell count and body temperature, and anorexia. A pulse rate of 120 beats/minute is higher than the normal range of 60 to 100 beats/minute. The white blood cell count of 13,000/µL is higher than the normal range of 4,500 to 10,000/µL. Inflammation results in increased metabolism and therefore increases the body temperature above the normal range of 97.8 to 99.1° F. The inflammation is manifested by increased respiratory rate. Normal respiratory rate is in the range of 12 to 18 breaths/minute; a rate of 10 breaths/minute does not indicate inflammation.

A nurse is responsible for the wound management of a bedridden patient with pressure ulcers. Which actions will help promote wound healing? Select all that apply. a. Cleaning the pressure ulcer with hydrogen peroxide b. Using a 30-mL syringe and a 19-gauge needle for irrigating the wound c. Keeping the pressure ulcer slightly moist to help proliferate epithelialization d. Removing the necrotic tissue on the pressure ulcer using autolytic debridement e. Using an irrigation pressure of 4 to 15 psi to adequately clean the pressure ulcer

ANS: B C D E Keeping the pressure ulcer slightly moist would help enhance epithelialization. Removing the necrotic tissue on the pressure ulcer by autolytic debridement helps expose the granulation tissue and helps to heal the wound. Using an irrigation pressure of 4 to 15 psi helps to adequately clean the pressure ulcer, thus facilitating the process of healing. This irrigation pressure can be created by using a 30-mL syringe and a 19-gauge needle for irrigating the wound. Hydrogen peroxide should not be used in cleaning the pressure ulcer because it is a cytotoxic solution that may damage fibroblasts, further deteriorating the wound.

The nurse is admitting a patient with a left leg injury. What assessment data does the nurse determine is indicative of inflammation at the site of the injury? Select all that apply. a. Odor at the site b. Swelling at the site c. Redness at the site d. Purulent exudate from the site e. Loss of function of cells at the site

ANS: B C E Inflammation increases the permeability of the blood vessels by causing vasodilation, resulting in redness at the site. Inflammation causes a shifting of fluids to the interstitial spaces and fluid accumulation, resulting in swelling at the site. Swelling and pain can result in loss of cellular function at the inflammatory site. Characteristic odor and purulent exudate at the site are signs of infection.

The nurse is caring for a patient who has a healing wound related to a fall and is encouraged to eat foods high in vitamin C. What food items should the nurse encourage the patient to ingest? Select all that apply. a. Seafood b. Broccoli c. Soy nuts d. Citrus fruits e. Yellow bell peppers

ANS: B D E High vitamin C foods include yellow bell peppers, broccoli, and citrus fruits. Seafood is high in zinc, not vitamin C. Soy nuts are a good source of protein, not vitamin C. Vitamin C is an essential nutrient required by the body for the development and maintenance of scar tissue, blood vessels, and cartilage.

The nurse is assessing a patient who has a tumorlike mass of scar tissue on an old abdominal wound. When documenting this information, which term should the nurse use? a. Adhesion b. Evisceration c. Keloid formation d. Fistula formation

ANS: C A keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may form tumorlike masses of scar tissue; therefore this is the term the nurse uses when documenting the patient's assessment data. Adhesions are bands of scar tissue that form between or around organs (such as the lungs or abdominal organs). Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound. A fistula formation is an abnormal passage between organs or a hollow organ and skin (such as abdominal or perianal fistula).

A patient is admitted to the medical unit with a 104.5° F temperature. Which nursing action would be most effective in restoring normal body temperature? a. Administer antibiotics as prescribed. b. Use a cooling blanket while the patient is febrile. c. Give antipyretics on an around-the-clock schedule. d. Have the unlicensed assistive personnel (UAP) give a sponge baths every two hours.

ANS: C Antipyretics are used to lower the body temperature and should be given around the clock to prevent acute swings in temperature. Chills may be evoked or perpetuated by the intermittent administration of antipyretics. These agents cause a sharp decrease in temperature. When the antipyretic wears off, the body may initiate a compensatory involuntary muscular contraction (i.e., chill) to raise the body temperature up to its previous level. This unpleasant side effect of antipyretic drugs can be prevented by administering the agents regularly and frequently at two- to four-hour intervals. Antibiotics are not used to lower the body's temperature. Sponge baths and cooling blankets may not decrease the body temperature unless antipyretic drugs have been given to lower the set point. Otherwise, the body will initiate compensatory mechanisms (e.g., shivering) to restore body heat.

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? 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

ANS: C Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, because tissue and nerve damage are significant risks. Exudate and infection normally would not accompany a soft tissue injury such as a sprain. Assessment of the circulation distal to the dressing site supersedes the importance of assessing the patient's mobility.

The nurse determines that a patient's abdominal surgical wound is healing by primary intention. Which phase best describes the migration of fibroblasts? a. Initial phase b. Maturation phase c. Granulation phase d. Regeneration phase

ANS: C The migration of fibroblasts occurs in the granulation phase, which lasts from five days to four weeks. In this phase, collagen is secreted and there is an abundance of capillary buds in the wound making it fragile. The initial phase lasts from three to five days. In this phase, the migration of epithelial cells takes place. The clot serves as a meshwork for starting capillary growth. The maturation phase lasts from seven days to several months. In this phase, remodeling of collagen and strengthening of the scar occurs. Regeneration is not the phase of primary intention healing.

The family of an older adult patient admitted with a severe infection asks the nurse how it could have happened so quickly without them noticing the signs. Which response by the nurse best answers the family's question? a. "Please try not to blame yourself; it can be hard to detect these kinds of issues in family members." b. "As people get older, they have a tendency to get much sicker at a much faster rate than when they were younger." c. "Older people often have less of a fever than younger individuals, which makes it harder to know something is happening." d. "You should have monitored them much more closely than you apparently have been so that you can catch such symptoms when they occur."

ANS: C Elderly adults have a blunted febrile response to infections, so a fever may be delayed or lower than what would be expected of younger patients. Telling the family not to blame themselves does not answer their question. Although elderly adults may be more prone to sickness for a variety of reasons, the overall statement that they get much sicker much faster is not valid. Telling the family that they should have done a better job of monitoring the patient is a judgmental statement that does not answer the question.

The primary health care provider instructs the nurse to elevate a patient's injured extremity. What should the nurse check for in the patient's reports before elevating the patient's extremity? a. Diabetes b. Cancer and other wounds c. Reduced arterial circulation d. Nonsteroidal antiinflammatory drug treatment

ANS: C Elevation of an extremity above the level of the heart increases venous and lymphatic return. To reduce the risk of compromised perfusion, the nurse should check the patient's reports for reduced arterial circulation before elevating the injured extremity. Diabetes does not cause complications due to elevation of an injured extremity. The nurse should check the patient's history for cancer and other wounds before administering becaplermin. Taking a nonsteroidal antiinflammatory drug may blunt the febrile response, but it does not cause complications while elevating an injured extremity.

Which physiologic change is associated with fever during inflammatory conditions? a. Increased blood flow rate b. Decreased neutrophil action c. Increased proliferation of T cells d. Suppressed activity of interferon

ANS: C Fever is mediated by a host macrophage product called endogenous pyrogen (EP) that stimulates the proliferation of T cells. Fever increases the action of neutrophils and promotes phagocytosis. Vasodilators increase blood flow rate. Fever increases destruction of microorganisms by enhancing the activity of interferon.

The nurse is preparing to administer a medication to a patient. The outcome of the medication is to prevent the liberation of lysosomes. What drug should the nurse administer to the patient? a. Ibuprofen b. Piroxicam c. Prednisone d. Acetaminophen

ANS: C Prednisone is an antiinflammatory drug that interferes with tissue granulation and induces immunosuppressive effects; thus, this drug prevents the liberation of lysosomes. Ibuprofen inhibits the synthesis of prostaglandins. Piroxicam is an antiinflammatory drug that inhibits the synthesis of prostaglandins. Acetaminophen is an antipyretic drug that lowers body temperature by acting on the heat-regulating center in the hypothalamus.

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 dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

ANS: C Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care.

Which data documented by the nurse concerning a pressure ulcer is subjective? a. Edema b. Discoloration c. Complaints of pain d. Moderate purulent drainage

ANS: C Reports of pain are considered subjective because the nurse cannot measure and observe it beyond the patient's reports. Edema, discoloration, and purulent drainage are objective data.

Which enzyme in the complement cascade depicted in this image is a potent vasodilator that contributes to edema and increased blood flow? a. Leukotrienes b. Thromboxane c. Prostaglandins d. Arachidonic acid

ANS: C The complement system is an enzyme cascade that mediates the inflammatory response. Prostaglandins are potent vasodilators that lead to increased blood flow and edema. After cell injury, arachidonic acid is converted to prostaglandins. Thromboxane leads to brief vasoconstriction and clot formation. The slow-reacting substance of anaphylaxis is formed by leukotrienes.

The nurse determines that the patient may be experiencing an acute bacterial infection. What laboratory result would confirm this suspicion? a. Increased platelet count b. Increased blood urea nitrogen c. Increased number of band neutrophils d. Increased number of segmented myelocytes

ANS: C The finding of an increased number of band neutrophils in circulation is called a shift to the left, which commonly is found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing, but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

A patient is one day postoperative after having a hernia repair. During the morning assessment, the nurse notes that the patient has incisional pain, a 99.2° F temperature, slight redness at the incision margins, and 20 mL of serosanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make? a. The abdominal incision is showing signs of an infection. b. The patient's abdominal hernia repair was not successful. c. The patient is experiencing a normal inflammatory response. d. The abdominal incision is showing signs of impending dehiscence.

ANS: C The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. Typical drainage from a surgical tube is serosanguineous; purulent drainage would indicate an infection. The response is normal, not a sign of infection or of impending dehiscence. The symptoms do not necessarily indicate the hernia repair was not successful.

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP informs the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? a. Notify the health care provider. b. Document the fistula formation. c. Assess the patient and vaginal drainage. d. Have the UAP apply a dressing to the vagina.

ANS: C With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse first should assess the patient and the drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care prescribed, provide care prescribed, and document the care and patient response.

An older adult patient is transferred from the nursing home with a black wound on the heel. What priority treatment should the nurse prepare the patient for? a. Dress it with an absorbent dressing for exudate. b. Handle the wound gently and let it dry out to heal. c. Debride the nonviable, eschar tissue to allow healing. d. Use negative-pressure wound (vacuum) therapy to facilitate healing.

ANS: C With a black wound the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and reepithelizing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement.

The nurse assesses that there is fecal material drainage coming from an abscess in the perianal area. Which complication of wound healing does the nurse suspect has occurred? a. Evisceration b. Keloid formation c. Fistula formation d. Hypertrophic scars

ANS: C Wound healing is the process in which the skin or other body tissue repairs itself after injury. Fistula is a complication of wound healing in which an abnormal passage is formed between organs or a hollow organ and skin. Evisceration is a complication of wound healing that occurs when wound edges separate to the extent that intestines protrude through the wound. Hypertrophic scars are inappropriately large, red, raised, and hard scars that occur due to overabundance of collagen during healing. Keloid extends beyond the edges of the wound and may form tumor-like masses of scar tissue.

A patient is admitted to the hospital with full thickness burns to the lower extremity and has developed eschar formation. What procedures should the nurse prepare the patient for to remove the eschar safely to accelerate the healing process in this patient? Select all that apply. a. Freeze debridement b. Thermal debridement c. Surgical escharotomy d. Enzymatic debridement e. Mechanical debridement

ANS: C D E Eschar is removed by surgical escharotomy, enzymatic debridement, and/or mechanical debridement. Surgical escharotomy involves removal of eschar by making a full-length incision on the eschar. In enzymatic debridement, the removal of necrotic tissues is done using an enzymatic preparation. Mechanical debridement involves removal of damaged dead tissues and cellular debris physically. Eschars are not removed by application of heat or by freezing and cryotherapy.

The nurse is caring for an older adult who has a compound fracture of the radius. The nurse observes manifestations of inflammation. Which symptoms should the nurse document as signs of infection in this older patient? Select all that apply. a. Reports of pain b. Presence of edema c. Temperature 100.8°F d. Respiratory rate of 30 e. Presence of erythema f. Heart rate 106 beats/min

ANS: C D F The nurse should assess this patient's vital signs; increase in temperature, pulse, and respiratory rates indicate the presence of infection. It is important for the nurse to note vital signs when an inflammation is present. Older adults have a blunted febrile response to infection, and body temperature may not rise as expected. Loss of function occurs due to pain and edema. Edema, erythema, and pain are local manifestations of inflammation. Normal ranges are as follows: temperature 97-99 degrees; respiratory rate 12-20 breaths/minute; heart rate 60-11 beats/minute.

The nurse is caring for a patient at risk for developing a pressure ulcer. What nursing action should be included in the plan of care to prevent the development of pressure ulcers? a. Sliding the patient instead of lifting when turning b. Repositioning the patient on a doughnut ring every three to four hours c. Applying lotion after the patient bathes and vigorously massaging the skin d. Implementing a turning schedule calling for position changes every one to two hours

ANS: D A turning schedule including proper documentation is the best way to ensure that the patient is repositioned every one to two hours. Sliding instead of lifting the patient causes friction and may result in skin tears. Placing a patient on a doughnut ring is contraindicated because it results in an area of pressure; three to four hours is too long between changes of position. Lotion applied to the skin does provide moisture, but vigorous massage may cause tissue damage.

A patient has fever associated with inflammation at an injury site. The nurse administers acetaminophen to the patient around the clock. What is the rationale behind this nursing intervention? a. To increase collagen synthesis b. To prevent liberation of lysosomes c. To increase power of white blood cells d. To prevent acute swings in temperature

ANS: D Acetaminophen is an antipyretic drug that inhibits the synthesis of prostaglandins. Acetaminophen lowers body temperature by acting on the heat-regulating center in the hypothalamus. This drug should be administered around the clock to prevent acute swings in temperature. Vitamin A supplements are used to increase collagen synthesis. Corticosteroids prevent liberation of lysosomes. Hyperbaric oxygen therapy increases the power of white blood cells.

The nurse has applied a compression bandage to a patient who has a knee joint injury. During a follow-up visit, the patient reports a loss of feeling in the affected extremity. The nurse also notices that the skin around the injured area is pale. What is the most appropriate nursing intervention in this situation? a. Administer zinc supplements to the patient. b. Assess the patient's white blood cell count. c. Administer vitamin C supplements to the patient. d. Take measures to ensure proper blood circulation.

ANS: D Although compression bandages occlude blood vessels and stop bleeding, they can compromise blood circulation. Loss of feeling in the extremity and pale skin around the injured area are signs of poor blood circulation. The nurse should take measures to ensure proper blood circulation. Zinc does not improve blood circulation. A change in white blood cell count may not affect blood circulation. Vitamin C supplements do not improve blood circulation.

The nurse is assessing four patients. Which patient may show catarrhal inflammatory exudate? a. A patient who has a venous ulcer. b. A patient who has pleural effusion. c. A patient who is bleeding after surgery. d. A patient with runny nose due to laryngitis.

ANS: D Catarrhal exudate is seen in a patient with a runny nose due to an upper respiratory tract infection (for example, laryngitis). Fibrinous exudate is observed in a patient with a venous ulcer; this exudate occurs because of increased vascular permeability and fibrinogen leakage into interstitial spaces. Hemorrhagic exudate is seen in a patient who is bleeding after surgery; this exudate is caused by a rupture of blood vessel walls. Serous exudate is seen in a patient with pleural effusion; this exudate occurs due to an outpouring of fluid.

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue

ANS: D Excess granulation tissue, the excess soft pink tissue on the wound, is this complication of wound healing. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.

The nurse is preparing to apply heat at the site of inflammation to a patient who sustained an injury to the arm. What is the best explanation to the patient as to the reason for this therapy? a. To decrease congestion b. To promote vasoconstriction c. To prevent further tissue injury d. To localize the inflammatory agents

ANS: D Heat application is used to localize the inflammatory agents and promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Cold application decreases congestion and promotes vasoconstriction at the site of inflammation. Immobilizing the inflamed area with a cast prevents further tissue injury.

The nurse is reviewing the laboratory data from four patients. Which patient's data from a white blood cell count with differential indicates a "shift to the left?" Patient A: Absence of eosinophils Patient B: Increased monocyte counts Patient C: Decreased number of lymphocyte Patient D: Presence of band neutrophils a. Patient A b. Patient B c. Patient C d. Patient D

ANS: D Immature forms of neutrophils called band neutrophils will be present early in the response to infection. This is referred to as a "shift to the left" and can be an early sign of the white blood cell response. Increased monocyte counts, decreased numbers of lymphocytes, and an absence of eosinophils are not referred to as a "shift to the left."

What manifestation is observed in a patient due to fluid shift to interstitial spaces in an inflammatory condition? a. Calor b. Dolor c. Rubor d. Tumor

ANS: D Inflammation causes a fluid shift to interstitial spaces and an accumulation of fluid exudate. This results in tumor. Calor occurs due to an increase in metabolism at the inflammatory site. Dolor occurs due to a change in pH and pressure from fluid exudate. Rubor occurs due to hyperemia from vasodilation.

What does the nurse expect to find in the laboratory report of a patient taking prednisone for rheumatoid arthritis? a. Increased prothrombin time b. Increased red blood cell count c. Decreased serum protein levels d. Decreased white blood cell count

ANS: D Prednisone is a corticosteroid drug that interferes with the synthesis of lymphocytes, resulting in a decreased white blood cell count. Prednisone does not interfere with prothrombin time. Prednisone does not increase red blood cell count because it does not stimulate erythropoiesis. Serum protein levels are not affected by prednisone.

A nursing student is learning about prostaglandins and their role in vasodilation. What is the source of prostaglandins? a. Cytokines b. Serotonin c. Histamine d. Arachidonic acid

ANS: D Prostaglandins are produced from arachidonic acid. When cells are activated by injury, the arachidonic acid in the cell membrane is converted to produce prostaglandins. Cytokines, serotonin, and histamine do not have any role in prostaglandin production. They are mediators of inflammation.

A patient has serosanguineous inflammatory exudate. What characteristic of this exudate should the nurse document? a. Presence of mucus b. Gelatinous ribbons c. Liquefied dead cells d. Semiclear pink exudate

ANS: D Serosanguineous inflammatory exudate is composed of red blood cells and will resemble semiclear pink exudate. Catarrhal exudate contains mucus. Fibrinous exudate looks like gelatinous ribbons. Purulent exudate contains liquefied dead cells.

A patient in an ambulatory care setting has been prescribed a semirigid brace to support a wrist injury. What action will the nurse take to ensure optimal comfort for the patient? a. Immobilize the wrist with a splint. b. Elevate the wrist above heart level. c. Provide cold application to the area. d. Assess distal pulses and capillary refill.

ANS: D The nurse should assess distal pulses and capillary refill before and after application of a semirigid brace or compression device to evaluate whether compression has compromised the patient's circulation. Cold application is appropriate at the time of initial trauma to promote vasoconstriction and decrease edema, pain, and congestion from increased metabolism in the area of inflammation. Immobilization of the inflamed or injured area promotes healing by decreasing the tissues' metabolic needs. Elevating the injured extremity above the level of the heart reduces the edema at the inflammatory site by increasing venous and lymphatic return.

The nurse is reviewing prescribed treatments for a patient with a debrided stage III sacral pressure ulcer. Which one of the prescriptions should a nurse question as part of the plan of care for a patient with this ulcer? a. Provide negative-pressure wound therapy. b. Turn and position the patient every two hours. c. Assess for pain and medicate before dressing change. d. Clean the ulcer every shift with povodone-iodine (Betadine) solution.

ANS: D Topical antimicrobials and antibactericidals (e.g., povidone-iodine, Dakin's solution [sodium hypochlorite], hydrogen peroxide [H 2O 2], chlorhexidine [Hibiclens]) should be used with caution in wound care because they can damage the new epithelium of healing tissue and delay healing. These topicals should never be used in a clean, granulating wound. It is appropriate to assess for pain and medicate before changing the dressing, turning the patient every two hours, and implementing negative-pressure wound therapy.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching? Select all that apply. a. Take the antibiotic until the wound feels better. b. Wound healing may not be complete for one to two weeks. c. Take the analgesic every day to promote adequate rest for healing. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. e. Notify the health care provider of redness, swelling, and increased drainage.

ANS: D E Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that is needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. B-complex vitamins facilitate metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every three to four hours) as needed. Wound healing may not be complete for four to six weeks or longer, not one to two weeks.