Exam 3: Inflammation & Wound Healing NCLEX Questions
b
A patient in the unit has a 103.7°F temperature. Which intervention would be the most effective in restoring normal body temperature? a. using a cooling blanket while the patient is febrile b. administer antipyretics on an around-the-clock schedule c. provide increased fluids and have the UAP give sponge baths d. give prescribed antibiotics and provide warm blankets for comfort
b
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? a. Pain level b. Intake and output c. Oxygen saturation d. Level of consciousness
b c
A 65 year old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are the most appropriate? (Select all that apply) a. acute pain related to tissue damage and inflammation b. impaired skin integrity related to immobility and decreased sensation c. impaired tissue integrity related to inadequate circulation secondary to pressure d. risk for infection related to loss of tissue integrity and under-nutrition secondary to stroke e. ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area
a
A basic principle of wound management for all open wounds is to a. Protect new granulation and epithelial tissue. b. Apply topical antimicrobials to prevent wound infection. c. Remove wound exudate with frequent dressing changes. d. Use occlusive dressings to prevent wound contamination.
b
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. tertiary intention b. secondary intention c. regeneration of cells d. remodeling of tissues
b
A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 X 10^6/µL, and he has coolness of the lower extremities, weighs 75 lbs. more than his ideal body weight, and smokes two packs of cigarettes a day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. imbalanced nutrition: obesity related to decreased blood flow secondary to diabetes and smoking b. impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. ineffective individual coping related to indifference and denial of long-term effects of diabetes and smoking
c d
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. Take the analgesic every day to promote adequate rest for healing. c. Be sure to wash hands after changing the dressing to avoid infection. 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.
b
A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight erythema at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. the abdominal incision shows signs of infection b. the patient is having a normal inflammatory response c. the abdominal incision shows signs of impending dehiscence d. the patient's physician must be notified about her condition
c
A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? a. Increased platelet count b. Increased blood urea nitrogen c. Increased number of band neutrophils d. Increased number of segmented myelocytes
d
A patient had a complicated vaginal hysterectomy. The student nurse provided perineal care after the patient had a bowel movement. The student nurse tells the nurse there was a lot of light brown, smelly drainage seeping from the vaginal area. What should the nurse suspect when assessing this patient? a. dehiscence b. hemorrhage c. keloid formation d. fistula formation
b
A patient had abdominal surgery 3 months ago and calls the clinic with complaints of severe abdominal pain and cramping, vomiting, and bloating. What should the nurse most likely suspect as the cause of the patient's problem? a. infection b. adhesion c. contracture d. evisceration
b
A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? a. Serous b. Purulent c. Fibrinous d. Catarrhal
c
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
d
A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue
b
A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? a. Warm, moist heat and massage b. Rest, ice, compression, and elevation c. Antipyretic and antibiotic drug therapy d. Active movement and exercise to prevent stiffness
b
A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? a. Administer aspirin on a scheduled basis around the clock. b. Provide acetaminophen every 4 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.
c
A patient's documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the patient's right hip? a. exposed bone, tendon, or muscle b. an abrasion, blister, or shallow crater c. deep crater through subcutaneous tissue to fascia d. persistent redness (or bluish color in darker skin tones)
b Rationale: Custard contains milk, egg, sugar, and vanilla. These contain calcium, vitamin A, and zinc, which are needed for wound healing
A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? a. Apple b. Custard c. Popsicle d. Potato chips
a
After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? a. Reposition every 2 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.
c
An 82 year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 X 2 X 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
a
An 85 year old patient is assessed to have a score of 16 on the Braden scale. Based on this information, how should the nurse plan for this patient's care? a. implement a 1 hr turning schedule with skin assessment b. place DuoDerm on the patient's sacrum to prevent breakdown c. elevate the head of bed to 90 degrees when the patient is supine d. continue with weekly skin assessments with no special precautions
c
An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? 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.
d
During care of patients, what is the most important precaution for preventing transmission of infections? a. wearing face and eye protection during routine daily care of the patient b. wearing nonsterile gloves when in contact with body fluids, excretions, and contaminated items c. wearing a gown to protect the skin and clothing during patient care activities likely to soil clothing d. hand washing after touching fluids and secretions, removing gloves, and between patient contacts
a
During the healing phase of inflammation, which cells would be most likely to regenerate? a. skin b. neurons c. cardiac muscle d. skeletal muscle
d
What role do the B-complex vitamins play in wound healing? a. decrease metabolism b. protect protein from being used for energy c. provide metabolic energy for the inflammation process d. coenzymes for fat, protein, and carbohydrate metabolism
a
What type of dressing will the nurse most likely use for the patient with a clean stage II pressure ulcer, with a red-pink wound bed, without slough? a. hydrocolloid b. transparent film c. absorptive dressing d. negative pressure wound therapy
d
In a patient with leukocytosis with a shift to the left, what does the nurse recognize as causing this finding? a. the complement system has been activated to enhance phagocytosis b. monocytes are released into the blood in larger-than-normal amounts c. the response to cellular injury is not adequate to remove damaged tissue and promote healing d. the demand for neutrophils causes the release of immature neutrophils from the bone marrow
c
Key interventions for treating initial soft tissue injury and resulting inflammation are remembered using the acronym RICE. What are the most important actions for the emergency department nurse to do for the patient with an ankle injury? a. reduce swelling, shine light on wound, control mobility, and get the history of the injury b. rub the wound clean, immobilize the area, cover the area protectively, and exercise the leg c. rest with immobility, apply a cold compress and/or a compression bandage, and elevate the ankle d. rinse the wounded ankle, get x-rays of the ankle, carry the patient, and extend the ankle with a splint
b
The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. serum protein analysis b. WBC count and differential c. punch biopsy of center of wound d. culture and sensitivity of the wound
d
The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? a. Fever and chills b. Increased blood pressure c. Increased respiratory rate d. General malaise and fatigue
b
Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? a. Keep the pressure ulcer clean and dry. b. Maintain protein intake of at least 1.25 g/kg/day. c. Use a 10-mL syringe to irrigate the pressure ulcer. d. Irrigate the pressure ulcer with hydrogen peroxide.
c
The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? 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.
a
The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? 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.
b
The patient has inflammation and reports tiredness, 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
c
The patient is admitted from home with a clean stage II pressure ulcer. What does the nurse expect to observe when she does her wound assessment? a. adherent gray necrotic tissue b. clean, moist granulating tissue c. red-pink wound bed, without slough d. creamy ivory to yellow-green exudate
d
The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcers does the nurse expect to see on admission? a. Stage I b. Stage II c. Stage III d. Stage IV
c
The patient's wound is not healing, so the HCP is going to send the patient home with negative pressure wound therapy. What will the caregiver need to understand about the use of this device? a. the wound must be cleaned daily b. the patient will be placed in a hyperbaric chamber c. the occlusive dressing must be sealed tightly to the skin d. the diet will not be as important with this sort of treatment
c
The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? 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.
a
To which patient should the nurse plan to administer around-the-clock antipyretic drugs? a. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F b. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F c. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F d. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F
c
What does the mechanism of chemotaxis accomplish? a. causes the transformation of monocytes into macrophages b. involves a pathway of chemical processes resulting in cellular lysis c. attracts the accumulation of neutrophils and monocytes to an area of injury d. slows the blood flow in a damaged area, allowing migration of leukocytes into tissue
d
What effect does the action of the complement system have on inflammation? a. modifies the inflammatory response to prevent stimulation of pain b. increases body temperature, resulting in destruction of microorganisms c. produces prostaglandins and leukotrienes that increase blood flow, edema, and pain d. increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis
b
What is characteristic of chronic inflammation? a. it may last 2-3 weeks b. the injurious agent persists or repeatedly injures tissue c. ineffective endocarditis is an example of chronic inflammation d. neutrophils are the predominant cell type at the site of inflammation
b
What is the most important nursing intervention for the prevention and treatment of pressure ulcers? a. using pressure-reduction devices b. repositioning the patient frequently c. massaging pressure areas with lotion d. using lift sheets and trapeze bars to facilitate patient movement
c
What is the primary difference between healing by primary intention and healing by secondary intention? a. primary healing requires surgical debridement for healing to occur b. primary healing involves suturing two layers of granulation tissue together c. presence of more granulation tissue in secondary healing results in a larger scar d. healing by secondary intention takes longer because more steps in the healing process are necessary
c
When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? a. White blood cell (WBC) count of 8000/ìL; temperature of 101°F b. White blood cell (WBC) count of 4000/ìL; temperature of 100°F c. White blood cell (WBC) count of 8500/ìL; temperature of 98.4°F d. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8°F
a
Which patient is most at risk for the development of a pressure ulcer? a. An older patient who is septic, bedridden, and incontinent b. An obese woman with leukemia who is receiving chemotherapy c. A middle-aged thin man in a halo cast after a motor vehicle accident d. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis
d e
Which nursing interventions for a patient with a stage IV sacral pressure ulcer are most appropriate to assign or delegate to a licensed practical/vocational nurse? (Select all that apply) a. assess and document wound appearance b. teach the patient pressure ulcer risk factors c. choose the type of dressing to apply to the ulcer d. measure the size (width, length, depth) of the ucler e. assist the patient to change positions at frequent intervals
c
Which nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing? a. fats b. proteins c. vitamin c d. vitamin a
c
Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer? a. pack the ulcer with foam dressing b. turn and position the patient every hour c. clean the ulcer every shift with Dakin's solution d. assess for pain and medicate before dressing change
c
Which patient is at the greatest risk for developing pressure ulcers? a. a 42 year old obese woman with type 2 diabetes b. a 78 year old man who is confused and malnourished c. a 30 year old man who is comatosed following a head injury d. a 65 year old woman who has urge and stress incontinence