Chapter 013 - Nursin

Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc.
Lewis: Medical-Surgical Nursing, 8

th
Edition
Chapter 13: Inflammation and Wound Healing
Test Bank
MULTIPLE CHOICE
1. The nurse assesses a surgical patient the morning oI the Iirst 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. NotiIy the health care provider.
d. Assess the wound every 2 hours.
ANS: B
The incisional redness and warmth are indicators oI the normal initial (inIlammatory)
stage oI wound healing by primary intention; the nurse should document the wound
appearance and continue to monitor the wound. NotiIication oI the health care provider,
assessment every 2 hours, and obtaining wound cultures are not indicated because the
healing is progressing normally.
DIE: Cognitive Level: Application REE: 192
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient with an open abdominal wound has a complete blood cell (CBC) count and
diIIerential, which indicate an increase in white blood cells (WBCs) and a shiIt to the leIt.
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 Ior purulent drainage.
ANS: A
The shiIt to the leIt indicates that the patient probably has a bacterial inIection, and the
nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may
be started, but cultures should be done Iirst. The nurse will continue to monitor the
wound, but additional actions are needed as well.
DIE: Cognitive Level: Application REE: 187 , 199 TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
3. A patient with a systemic bacterial inIection has 'goose pimples, Ieels cold, and has a
shaking chill. At this stage oI the Iebrile response, the nurse will plan to monitor Ior
a. skin Ilushing.
b. muscle cramps.
c. rising body temperature.
Test Bank
13-2
d. decreasing blood pressure.
ANS: C
The patient`s complaints oI Ieeling cold and shivering indicate that the hypothalamic set
point Ior temperature has been increased and the temperature is increasing. Because
associated peripheral vasoconstriction and sympathetic nervous system stimulation will
occur, skin Ilushing and hypotension are not expected. Muscle cramps are not expected
with chills and shivering or with rising temperatures.
4. A 24-year-old patient who is receiving antibiotics Ior an inIected leg wound has a
temperature oI 101.8 E (38.7 C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket.
b. NotiIy the health care provider.
c. Give the prescribed PRN aspirin (Ascriptin) 650 mg.
d. Check the patient`s oral temperature again in 4 hours.
ANS: D
Mild to moderate temperature elevations (less than 103 E) do not harm the young adult
patient and may beneIit host deIense mechanisms. The nurse should continue to monitor
the temperature. Antipyretics are not indicated unless the patient is complaining oI Iever-
related symptoms. There is no need to notiIy the patient`s health care provider or to use a
cooling blanket Ior a moderate temperature elevation.
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. 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 Ior wound care?
a. Dry gauze dressing (Kerlix)
b. Nonadherent dressing (XeroIorm)
c. Hydrocolloid dressing (DuoDerm)
d. Transparent Iilm dressing (Tegaderm)
ANS: C
The wound requires debridement oI the necrotic areas and absorption oI the yellow-green
slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals.
Transparent Iilm dressings are used Ior 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.
DIE: Cognitive Level: Application REE: 196-197
6. A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy
exudate and small areas oI deep pink granulation tissue. The nurse documents the wound
as a
Test Bank
13-3
a. red wound.
b. yellow wound.
c. Iull-thickness wound.
d. stage III pressure wound.
ANS: B
The description is consistent with a yellow wound. A stage III pressure wound would
expose subcutaneous Iat. A red wound would not have any creamy colored exudate. A
Iull-thickness wound involves subcutaneous tissue, which is not indicated in the wound
description.
DIE: Cognitive Level: Comprehension REE: 193-194
7. Which nursing action is most likely to detect early signs oI inIection in a patient who is
taking immunosuppressive medications?
a. Monitor white blood cell count.
b. Check the skin Ior areas oI redness.
c. Check the temperature every 2 hours.
d. Ask about Iatigue or Ieelings oI malaise.
ANS: D
Common clinical maniIestations oI inIlammation and inIection are Irequently not present
when patients receive immunosuppressive medications. The earliest maniIestation oI an
inIection may be 'just not Ieeling well.
8. The nurse will plan to use wet-to-dry dressings when providing care Ior a patient with a
a pressure ulcer with pink granulation tissue.
a. surgical incision with pink, approximated edges.
b. Iull-thickness burn Iilled with dry, black material.
c. wound with purulent drainage and dry brown areas.
ANS: C
Wet-to-dry dressings are used when there is minimal eschar to be removed. A Iull-
thickness wound Iilled 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 uninIected
granulating wounds because oI the damage to the granulation tissue.
DIE: Cognitive Level: Application REE: 198 TOP: Nursing Process:
Planning
9. A patient is admitted to the hospital with a pressure ulcer on the leIt buttock. The base oI
the wound is yellow and involves subcutaneous tissue. The nurse classiIies the pressure
ulcer as stage
Test Bank
13-4
a. I.
b. II.
c. III.
d. IV.
ANS: C
A stage III pressure ulcer has Iull-thickness skin damage and extends into the
subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable
damage such as redness or a boggy Ieel. Stage II pressure ulcers have partial-thickness
skin loss. Stage IV pressure ulcers have Iull-thickness damage with tissue necrosis,
extensive damage, or damage to bone, muscle, or supporting tissues.
DIE: Cognitive Level: Comprehension REE: 200
10. A patient who is conIined to bed and who has a stage II pressure ulcer is being cared Ior
in the home by Iamily members. To prevent Iurther tissue damage, the home care nurse
instructs the Iamily members that it is most important to
a. change the patient`s bedding Irequently.
b. use a hydrocolloid dressing over the ulcer.
c. record the size and appearance oI the ulcer weekly.
d. change the patient`s position at least every 2 hours.
ANS: D
The most important intervention is to avoid prolonged pressure on bony prominences by
Irequent repositioning. The other interventions also may be included in Iamily teaching,
but the most important instruction is to change the patient`s position at least every 2
hours.
11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing
change Ior a patient`s stage III sacral pressure ulcer?
a. Administer the ordered PRN oral opioid 30 minutes beIore the dressing change.
b. Soak the old dressings with sterile saline a Iew minutes beIore removing them.
c. Pour sterile saline onto the new dry dressings aIter the wound has been packed.
d. Apply antimicrobial ointment beIore repacking the wound with moist dressings.
ANS: A
Mechanical debridement with wet-to-dry dressings is painIul, and patients should receive
pain medications beIore the dressing change begins. The new dressings are moistened
with saline beIore being applied to the wound. Soaking the old dressings beIore removing
them will eliminate the wound debridement that is the purpose oI this type oI dressing.
Application oI antimicrobial ointments is not indicated Ior a wet-to-dry dressing.
DIE: Cognitive Level: Application REE: 198 , 202
Test Bank
13-5
12. The charge nurse observes a new graduate perIorming a dressing change on a stage II leIt
heel pressure ulcer. Which action by the new graduate indicates a need Ior Iurther
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 halI-strength
peroxide.
ANS: D
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen
peroxide. The other actions by the new graduate are appropriate.
DIE: Cognitive Level: Application REE: 202 TOP: Nursing Process:
Evaluation
MSC: NCLEX: SaIe and EIIective Care Environment
13. A patient arrives in the emergency department with a swollen ankle aIter 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 oI motion (ROM).
ANS: A
SoIt tissue injuries are treated with rest, ice, compression, and elevation (RICE).
Elevation oI the ankle will decrease tissue swelling. Moving the ankle through the ROM
will increase swelling and risk Iurther injury. Cold packs should be applied the Iirst 24
hours to reduce swelling. The soccer shoe does not need to be removed immediately and
will help to compress the injury iI it is leIt in place.
14. When admitting a patient with stage III pressure ulcers on both heels, which inIormation
obtained by the nurse will have the most impact on wound healing?
a. The patient states that the ulcers are very painIul.
b. The patient has had the heel ulcers Ior the last 6 months.
c. The patient has several old incisions that have Iormed keloids.
d. The patient takes corticosteroids daily Ior rheumatoid arthritis.
ANS: D
Chronic corticosteroid use will interIere with wound healing. The persistence oI the
ulcers over the last 6 months is a concern, but changes in care may be eIIective in
promoting healing. Keloids are not disabling or painIul, although the cosmetic eIIects
may be distressing Ior some patients. Actions to reduce the patient`s pain will be
implemented, but pain does not impact directly on wound healing.
Test Bank
13-6
15. The nurse has just received change-oI-shiIt report about the Iollowing Iour patients.
Which patient will the nurse assess Iirst?
a. The patient who has multiple black wounds on the Ieet 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 beIore a scheduled
dressing change.
d. The patient who has been receiving immunosuppressant medications and has a
temperature oI 102 E.
ANS: D
Even a low Iever in an immunosuppressed patient is a sign oI serious inIection and
should be treated immediately with cultures and rapid initiation oI antibiotic therapy. The
nurse should assess the other patients as soon as possible aIter assessing and
implementing appropriate care Ior the immunosuppressed patient.
DIE: Cognitive Level: Analysis REE: 190
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
16. Which oI these Iour 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 aIter suturing oI a Iull-thickness arm wound.
c. The patient who needs teaching about home care Ior a draining abdominal wound.
d. The patient who requires a hydrocolloid dressing change Ior a Stage III sacral
ulcer.
ANS: D
LPN education and scope oI practice include sterile dressing changes Ior stable patients.
Initial wound assessments, patient teaching, and evaluation Ior possible poor wound
healing or inIection should be done by the RN.
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
17. When caring Ior a diabetic patient who had abdominal surgery one week ago, the nurse
obtains these data. Which Iinding should be reported immediately to the health care
provider?
a. Blood glucose 136 mg/dl
b. Oral temperature 101 E (38.3 C)
c. Patient complaint oI increased incisional pain
d. New 5-cm separation oI the proximal wound edges
ANS: D
Test Bank
13-7
Wound separation at a week postoperatively indicates possible wound dehiscence and
should be immediately reported to the health care provider. The other Iindings also will
be reported, but do not require intervention as rapidly.
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
18. A diabetic patient is admitted Ior a laparotomy and possible release oI 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 E (38.9 C).
d. redressing the surgical incision with a dry, sterile dressing twice daily.
ANS: A
Elevated blood glucose will have an impact on multiple Iactors involved in wound
healing. Ensuring adequate nutrition also is important Ior the postoperative patient, but a
higher priority is blood glucose control. A temperature oI 102 E will not impact
adversely on wound healing, although the nurse may administer antipyretics iI the patient
is uncomIortable. Application oI a dry, sterile dressing daily may be ordered, but Irequent
dressing changes Ior a wound healing by primary intention is not necessary to promote
wound healing.
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
COMPLETION
1. A patient`s temperature has been 101 E (38.3 C) Ior several days. The patient`s normal
caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the
metabolic rate increases 7 Ior each Eahrenheit degree above 100 in body temperature,
calculate the total calories the patient should receive each day.
ANS: 2140
OBJ: Special Questions: Alternate Item Eormat
2. A patient who has an inIected abdominal wound develops a temperature oI 104 E (40
C). All the Iollowing interventions are included in the patient`s plan oI care. In which
order should the nurse perIorm the Iollowing actions? Put a comma and space between
each answer choice (a, b, c, d, etc.)
a. Sponge patient with cool water.
b. Administer intravenous antibiotics.
c. PerIorm wet-to-dry dressing change.
Test Bank
13-8
d. Administer acetaminophen (Tylenol).
ANS:
B, D, A, C
The Iirst action should be to administer the antibiotic because treating the inIection that
has caused the Iever is the most important aspect oI Iever management. The next priority
is to lower the high Iever, so the nurse should administer acetaminophen to lower the
temperature set point. A cool sponge bath should be done aIter the acetaminophen is
given to lower the temperature Iurther. The wet-to-dry dressing change will not have an
immediate impact on the inIection or Iever and should be done last.
DIE: Cognitive Level: Analysis REE: 190 , 199
OBJ: Special Questions: Alternate Item Eormat, Prioritization TOP: Nursing Process:
Planning

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Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc.

Lewis: Medical-Surgical Nursing, 8

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