Deck 14: Inflammation and Wound Healing

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?

A)1
B)2
C)3
D)4

Answer 1

3

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?

A)Blood glucose 7.6 mmol/L
B)Oral temperature 38.3°C (100.9°F)
C)Client has increased incisional pain
D)New 5-cm separation of the proximal wound edges

Answer 2

New 5-cm separation of the proximal wound edges

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?

A)Administer the ordered PRN oral opioid 30 minutes before the dressing change.
B)Soak the old dressings with sterile saline a few minutes before removing them.
C)Pour sterile saline onto the new dry dressings after the wound has been packed.
D)Apply antimicrobial ointment before repacking the wound with moist dressings.

Answer 3

Administer the ordered PRN oral opioid 30 minutes before the dressing change.

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.

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?

A)Skin flushing
B)Muscle cramps
C)Rising body temperature
D)Decreasing blood pressure

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?

A)Every 4 hours
B)Every 6 hours
C)Every 12 hours
D)Every 24 hours

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?

A)Dry gauze dressing (Kerlix)
B)Nonadherent dressing (Xeroform)
C)Hydrocolloid dressing (DuoDerm)
D)Transparent film dressing (Tegaderm)

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?

A)Apply a cooling blanket.
B)Notify the health care provider.
C)Give the prescribed PRN Aspirin 650 mg.
D)Check the client's oral temperature again in 4 hours.

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?

A)Change the client's bedding frequently.
B)Use a hydrocolloid dressing over the injury.
C)Record the size and appearance of the pressure injury weekly.
D)Change the client's position every 2 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?

A)Monitor white blood cell count.
B)Check the skin for areas of redness.
C)Check the temperature every 2 hours.
D)Ask about fatigue or feelings of malaise.

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?

A)Red wound
B)Yellow wound
C)Full-thickness wound

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?

A)Uses a hydrocolloid dressing (DuoDerm) to cover the injury.
B)Inserts a sterile cotton-tipped applicator into the pressure injury.
C)Irrigates the pressure injury with a 30-mL syringe using sterile saline.
D)Cleans the injury with a sterile dressing soaked in half-strength hydrogen peroxide.

Question 13

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

A)The client who has multiple black wounds on the feet and ankles.
B)The newly admitted client with a stage IV pressure injury on the coccyx.
C)The client who needs to be medicated with multiple analgesics before a scheduled dressing change.
D)The client who has been receiving immunosuppressant medications and has a temperature of 38.9°C (102°F).

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?

A)The client states that the injuries are very painful.
B)The client has had the heel injuries for the last 6 months.
C)The client has several old incisions that have formed keloids.
D)The client takes corticosteroids daily for rheumatoid arthritis.

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?

A)Elevate the ankle above heart level.
B)Remove the client's shoe and sock.
C)Apply a warm moist pack to the ankle.
D)Assess the ankle's range of motion (ROM).

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?

A)Maintaining the client's blood glucose within a normal range
B)Ensuring that the client has an adequate dietary protein intake
C)Giving antipyretics to keep the temperature less than 38.9°C (102°F)
D)Redressing the surgical incision with a dry, sterile dressing twice daily

Question 17

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

A)Initial phase
B)Granulation phase
C)Maturation phase
D)Reoccurrence phase

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?

A)Pressure injury with pink granulation tissue
B)Surgical incision with pink, approximated edges
C)Full-thickness burn filled with dry, black material
D)Wound with purulent drainage and dry brown areas

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?

A)Obtain wound cultures.
B)Start antibiotic therapy.
C)Redress the wound with wet-to-dry dressings.
D)Continue to monitor the wound for purulent drainage.

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?

A)Obtain wound cultures.
B)Document the assessment.
C)Notify the health care provider.
D)Assess the wound every 2 hours.

Question 21

Aclient who has an infected abdominal wound develops a temperature of 40°C (104°F). All the following interventions are included in the client's plan of care. In which order should the nurse perform the following actions?

A)Sponge client with cool water.
B)Administer intravenous antibiotics.
C)Perform wet-to-dry dressing change.
D)Administer acetaminophen.