Chapter 013 Inflamation

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Lewis: Medical-Surgical Nursing, 7

th
Edition

Chapter 13: Inflammation and Wound Healing

MULTIPLE CHOICE

1. 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. Notify the health care provider.
b. Document the assessment.
c. Assess the wound every 2 hours.
d. Obtain wound cultures.

Correct Answer: B
Rationale: The incisional redness and warmth are signs of normal wound healing, and the nurse should document the wound
appearance and continue to monitor the wound every shift. Notification of the health care provider, assessment every 2 hours, and
obtaining wound cultures are not indicated because the healing is progressing normally.

Cognitive Level: Application Text Reference: p. 197
Nursing Process: Assessment NCLEX: Physiological Integrity

2. When caring for a patient after an abdominal surgery, the nurse will be most concerned about monitoring for wound
dehiscence during which period?
a. The first postoperative day
b. The third postoperative day
c. One week after the surgery
d. One month after the surgery

Correct Answer: C
Rationale: The patient is at risk for dehiscence during the granulation phase of wound healing, which lasts from the fifth
postoperative day to 3 weeks after surgery. The other times are not high-risk periods for dehiscence.

Cognitive Level: Application Text Reference: pp. 198-199

3. A patient with an open abdominal wound has a complete blood cell (CBC) count and white blood cell (WBC) differential,
which indicates a shift to the left. The nurse will anticipate that the next collaborative intervention will be to
a. redress the wound with wet-to-dry dressings.
b. obtain wound cultures.
c. start antibiotic therapy.
d. continue to monitor the wound for purulent drainage.

Correct Answer: B
Rationale: The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain
wound cultures and start antibiotic therapy. Wet-to-dry dressing changes may be ordered based on the characteristics of the
wound, but these will be started after the wound culture and initiation of antibiotic therapy. The nurse will continue to monitor
the wound, but additional actions are needed as well.

Nursing Process: Planning NCLEX: Physiological Integrity

4. 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 would expect to find
a. skin flushing.
b. rising body temperature.
c. decreasing blood pressure.
d. muscle cramps.

Correct Answer: B

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Rationale: The patients 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.


5. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F. Which action by
the nurse is most appropriate?
a. Check the temperature again in 4 hours.
b. Administer aspirin (Ecotrin) every 4 to 6 hours.
c. Notify the health care provider.
d. Apply a cooling blanket.

Correct Answer: A
Rationale: Mild to moderate temperature elevations (less than 103 F) do not harm the young adult patient and may benefit host
defense mechanisms; the nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is
complaining of fever-related symptoms. There is no need to notify the patients health care provider or to use a cooling blanket
for a moderate temperature elevation.

Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patients 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing
will the nurse anticipate using for wound care?
a. Transparent film dressing (Tegaderm)
b. Dry gauze dressing (Kerlix)
c. Hydrocolloid dressing (DuoDerm)
d. Nonadherent dressing (Xeroform)

Correct Answer: C
Rationale: The wound requires debridement of the necrotic areas; absorption of the yellow-green slough and 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.

Cognitive Level: Application Text Reference: pp. 200, 204, 205

7. The nurse is admitting a diabetic patient who is scheduled for a laparotomy and possible release of adhesions. When
planning interventions to promote wound healing, the nurse will be most concerned about
a. maintaining the patients blood glucose in a normal range.
b. ensuring that the patient obtains an adequate amount of dietary carbohydrates.
c. administration of antipyretics to keep the temperature less than 103 F.
d. applying a dry, sterile dressing to the surgical incision daily.

Correct Answer: A
Rationale: Elevated blood glucose will impact on multiple factors involved in wound healing. Assuring adequate nutrition is also
important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 103 F will not impact
adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry,
sterile dressing daily may be ordered, but a daily dressing change for a wound healing by primary intention is not necessary to
promote wound healing.


8. A 76-year-old patient has a large open, infected surgical wound on the abdomen that contains a creamy exudate and small
areas of deep pink granulation tissue. The nurse will document the wound as a
a. stage III pressure wound.
b. yellow wound.
c. red wound.
d. full-thickness wound.

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Correct Answer: B
Rationale: The description is consistent with a yellow wound. An abdominal surgical wound will not lead to a pressure ulcer. A
red wound would not have any creamy colored exudate. A full thickness wound will involve subcutaneous tissue, which is not
indicated in the wound description.

Cognitive Level: Comprehension Text Reference: p. 200

9. A patient with massive trauma to the leg has a 7 cm by 10 cm full-thickness leg wound with extensive skeletal muscle
damage and wide, irregular wound edges. The nurse will teach the patient that
a. all of the damaged tissue will regenerate if infection does not occur.
b. most of the skin and skeletal muscle will be replaced by connective tissue.
c. the skin will regenerate to cover the injury but the muscle will not be replaced.
d. complete regeneration of skin and muscle tissue will take several months.

Correct Answer: B
Rationale: Traumatic wounds such as this one heal by secondary intention, and much of the skin and skeletal muscle will be
replaced by connective tissue. Some, but not all, of the skin and skeletal muscle will regenerate. Some skin regeneration will
occur, but because the wound is wide and will heal by secondary intention, some scar tissue will form. Complete regeneration of
skin and muscle in this type of wound will not occur.


10. The nurse will plan to use wet-to-dry dressings when providing care for a
a. full-thickness burn filled with dry, black material.
b. surgical incision with pink, approximated edges.
c. pressure ulcer with pink granulation tissue.
d. wound with purulent drainage and dry brown areas.

Correct Answer: D
Rationale: 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.


11. A patient is admitted to the hospital with an infected pressure ulcer on the left buttock. The pressure ulcer is 5 cm long by
2.5 cm wide and is 1.5 cm deep. 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.

Correct Answer: C
Rationale: A stage III pressure ulcer has full-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 feel. Stage II pressure ulcers have partial-thickness
skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone,
muscle, or supporting tissues.


12. A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To
prevent further tissue damage, the home care nurse instructs the family members that it is most important to
a. change the patients bedding at least every day.
b. record the size and appearance of the ulcer weekly.
c. provide the patient with a high-calorie, high-protein diet.
d. change the patients position at least every 2 hours.

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Correct Answer: D
Rationale: The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The
other interventions may also be taught and will help to prevent worsening of the ulcer, but the most important instruction is to
change the patients position at least every 2 hours.


13. The nurse is preparing to perform a wet-to-dry dressing change for a patient with infected leg burns. Which action is
appropriate for this type of dressing change?
a. Administer the ordered prn oral opioid 30 minutes before the dressing change.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Soak the old dressings with sterile saline a few minutes before removing them.
d. Spread SilverDerm ointment into the wound before repacking with moist dressings.

Correct Answer: A
Rationale: Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the
dressing change begins. The new dressings are moistened with saline prior to being applied to the wound. Soaking the old
dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of
antimicrobial ointments is not included in wet-to-dry dressings.


14. The charge nurse observes a new graduate performing a dressing change on a stage III sacral 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.

Correct Answer: D
Rationale: Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions
by the new graduate are appropriate.

Nursing Process: Evaluation
NCLEX: Safe and Effective Care Environment

15. The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess
first?
a. The newly admitted patient with a stage IV pressure ulcer on the coccyx.
b. The patient who has been receiving immunosuppressant medications and has a temperature of 102 F.
c. The patient who has multiple black wounds on the feet and ankles.
d. The patient who needs to be medicated with multiple analgesics prior to a scheduled dressing change.

Correct Answer: B
Rationale: Even a low fever in an immunosuppressed patient 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 patients as soon as possible after
assessing and implementing appropriate care for the patient with a fever.

Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment

16. 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. Assess the ankles range of motion (ROM).
b. Apply a warm moist pack to the ankle.
c. Wrap the ankle with a compression bandage.
d. Remove the patients soccer shoe and sock.

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Correct Answer: C
Rationale: RICE treatment is used for soft tissue injuries. Use of a compression bandage around 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.


17. When admitting a patient with a stage III pressure ulcers on both heels, which information obtained by the nurse is of most
concern?
a. The patient takes corticosteroids daily for rheumatoid arthritis.
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 patients admission oral temperature is 102 F.

Correct Answer: A
Rationale: Chronic corticosteroid use will interfere with wound healing. The persistence of the ulcers 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 patients. An admission temperature of 102 F requires assessment of the cause and treatment,
but is not necessarily a concern for wound healing.

Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

SHORT ANSWER

1. A patients temperature has been 101 F (38.3 C) for several days. The patients 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.

Correct Answer:
2140


OTHER

1. A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions
are included in the patients plan of care. In which order will the nurse perform the following actions?
a. Administer acetaminophen (Tylenol).
b. Perform wet-to-dry dressing change.
c. Administer intravenous antibiotics.
d. Sponge patient with cool water.

Correct Answer:
C, A, D, B
Rationale: The first action should be to administer the antibiotic because treating the infection that has caused the fever is the
most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer
acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower
the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should
be done last.


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Lewis: Medical-Surgical Nursing, 7

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