Question 1

Aclient is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?

Accepted Answer

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.

Question 2

The nurse is caring for a client with diabetes who had abdominal surgery one week ago, and obtains the following data. Which of these findings should be reported immediately to the health care provider?

Accepted Answer

Wound separation at a week postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings also will be reported, but do not require intervention as rapidly.

Question 3

Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a client who has a stage III sacral pressure injury?

Accepted Answer

Mechanical debridement with wet-to-dry dressings is painful, and clients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type ofdressing.
Application of antimicrobial ointments is not indicated for a wet-to-drydressing.

Question 4

A client's temperature has been 38.8°C (101.8°F) for several days. The client's normal caloric intake to meet nutritional needs is 2 000 calories per day. Knowing that the metabolic rate increases 13% for every 1°C (33.8°F) increase in temperature above 37.8°C (100°F) in body temperature, calculate the total calories the client should receive each day.

Accepted Answer

The answer of A client's temperature has been 38.8°C (101.8°F)...

Question 5

The nurse is caring for a client with a systemic bacterial infection that has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, which of the following assessments should the nurse monitor?

Accepted Answer

The client's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.

Question 6

The nurse is caring for an adult client with stage 3 pressure injuries on both heels who has been in hospital for 6 days. Which of the following timeframes for wound assessment is accurate when a client is in the acute care setting?

Accepted Answer

In acute care, the client should be reassessed every 24 hours. In long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and at least monthly or every 3 months thereafter.

Question 7

Aclient's 6 * 3 cm leg wound has a 2 mm black area surrounded by yellow-green semiliquid material. Which of the following dressings should the nurse use for wound care?

Accepted Answer

The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals.
Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

Question 8

The nurse is caring for a young adult client who is receiving antibiotics for an infected leg wound and has a temperature of 38.8°C (101.8°F). Which of the following actions by the nurse is most appropriate?

Accepted Answer

Mild to moderate temperature elevations (less than 39.5°C [103.1°F]) do not harm the young adult client and may benefit host defence mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the client is complaining of fever-related symptoms. There is no need to notify the client's health care provider or to use a cooling blanket for a moderate temperature elevation.

Question 9

A client who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions should the nurse instruct the family members that it is most important?

Accepted Answer

The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions also may be included in family teaching, but the most important instruction is to change the client's position every 2-4 hours.

Question 10

Which of the following nursing actions is most likely to detect early signs of infection in a client who is taking immuno-suppressive medications?

Accepted Answer

Common clinical manifestations of inflammation and infection are frequently not present when clients receive immuno-suppressive medications. The earliest manifestation of an infection may be "just not feeling well."

Question 11

The nurse is caring for a client who has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. Which of the following terms should the nurse use to document these findings?

Accepted Answer

The description is consistent with a yellow wound. A stage III pressure wound would expose subcutaneous fat. A red wound would not have any creamy coloured exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description.

Question 12

The charge nurse observes a new graduate performing a dressing change on a client with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?

Accepted Answer

Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.

Question 13

The nurse has just received change-of-shift report about the following four r. Which client will the nurse assess first?

Accepted Answer

Even a low fever in an immuno-suppressed client is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other clients as soon as possible after assessing and implementing appropriate care for the immuno-suppressed client.

Question 14

The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the following information obtained by the nurse will have the most impact on wound healing?

Accepted Answer

Chronic corticosteroid use will interfere with wound healing. The persistence of the pressure injuries over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some clients. Actions to reduce the client's pain will be implemented, but pain does not impact directly on wound healing.

Question 15

A client arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which of the following actions by the nurse is most appropriate?

Accepted Answer

Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The soccer shoe does not need to be removed immediately and will help to compress the injury if it is left in place.

Question 16

The nurse is caring for a client with diabetes who has been admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, which of the following actions is priority?

Accepted Answer

Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative client, but a higher priority is blood glucose control. A temperature of 38.9°C (102°F) will not impact wound healing adversely, although the nurse may administer antipyretics if the client 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.

Question 17

During wound healing, a wound is resistant to infection during which of the following phases?

Accepted Answer

A wound is resistant to infection during the granulation phase of wound healing.

Question 18

The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?

Accepted Answer

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.

Question 19

Aclient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is priority as a result of this assessment data?

Accepted Answer

The shift to the left indicates that the client probably has a bacterial infection, and the nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

Question 20

The nurse is assessing a client the morning of the first postoperative day and notes redness and warmth around the incision. Which of the following actions should the nurse implement?

Accepted Answer

The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention; the nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

Quiz 14: Inflammation and Wound Healing