Chapter 11: Inflammation and Healing
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
b. Separation of proximal wound edges
After receiving a change-of-shift report, which patient should the nurse assess first?
b. The patient receiving chemotherapy who has a temperature of 102° F.
When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing?
b. The patient takes oral hypoglycemic agents daily.
A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories perday. If the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?
ANS: 2140 calories
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.
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?
a. Low serum albumin level Serum protein levels may decrease with negative pressure therapy, which will adversely affect wound healing. The other findings are expected with wound healing
A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority?
a. Maintaining the patient's blood glucose within a normal range
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care?
a. The new nurse cleans the injury with half-strength peroxide.
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?
b. Document the assessment.
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?
d. Undermining Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrower "lip" around the wound, which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and maceration refer to loosening friable tissue.
The nurse will perform which action for a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury?
b. Administer a prescribed PRN oral analgesic 30 minutes before the change. Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound but not soaked after packing. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.
The nurse should plan to use a wet-to-dry dressing for which patient?
d. A patient who has a wound with purulent drainage and dry brown areas. Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?
d. Ask about feelings of fatigue or malaise.
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/VN)?
d. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
c. Rising body temperature
.A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?
c. Stage 3 A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue. A stage 1 pressure injury has intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injuries have partial-thickness skin loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed?
c. The family member dries the wound using a hair dryer on a low setting.
A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?
c. Change the patient's position every 1 to 2 hours.
A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient denies any discomfort. Which action by the nurse is appropriate?
c. Check the patient's temperature again in 4 hours.
A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
c. Hydrocolloid dressing