Deck 13: Inflammation and Wound Healing

Question 1

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate?

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

Answer 1

Elevate the ankle above heart level.

Question 2

A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage

A) I.
B) II.
C) III.
D) IV.

Answer 2

III.

Question 3

Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's stage III sacral pressure ulcer?

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 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a

A) red wound.
B) yellow wound.
C) full-thickness wound.
D) stage III pressure wound.

Question 5

A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

A) change the patient's bedding frequently.
B) use a hydrocolloid dressing over the ulcer.
C) record the size and appearance of the ulcer weekly.
D) change the patient's position at least every 2 hours.

Question 6

The charge nurse observes a new graduate performing a dressing change on a stage II left heel pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care?

A) The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.
B) The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer.
C) The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline.
D) The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

Question 7

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 per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, calculate the total calories the patient should receive each day. ____________________

Question 8

A patient who has an infected abdominal wound develops a temperature of 104°F ( 40° C ). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? Put a comma and space between each solve choice ( a, b, c, d, etc. ) ____________________

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

Question 9

Which of these four patients should the medical-surgical unit charge nurse assign to an LPN team member?

A) The patient who has increased tenderness and swelling around a leg wound.
B) The patient who has just arrived after suturing of a full-thickness arm wound.
C) The patient who needs teaching about home care for a draining abdominal wound.
D) The patient who requires a hydrocolloid dressing change for a Stage III sacral ulcer.

Question 10

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

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

Question 11

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

Question 12

The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?

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

Question 13

When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider?

A) Blood glucose 136 mg/dl
B) Oral temperature 101° F ( 38.3° C )
C) Patient complaint of increased incisional pain
D) New 5-cm separation of the proximal wound edges

Question 14

A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F ( 38.7° C ). Which action by the nurse is most appropriate?

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

Question 15

A patient's 6 *3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will 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 16

Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive 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 17

A diabetic patient is admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, the nurse's highest priority will be

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.

Question 18

A patient 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. The nurse anticipates that the next action will be to

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 19

The nurse will plan to use wet-to-dry dressings when providing care for a patient with a

A) pressure ulcer 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 20

A patient with a systemic bacterial infection has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for

A) skin flushing.
B) muscle cramps.
C) rising body temperature.
D) decreasing blood pressure.