Deck 13: Inflammation and Wound Healing

Question 1

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.

Answer 1

The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

Question 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

Answer 2

One week after the surgery

Question 3

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.

Answer 3

rising body temperature.

Question 4

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.

Question 5

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 ankle's range of motion (ROM).
B) Apply a warm moist pack to the ankle.
C) Wrap the ankle with a compression bandage.
D) Remove the patient's soccer shoe and sock.

Question 6

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.

Question 7

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.

Question 8

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 patient's 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.

Question 9

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.

Question 10

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 patient's admission oral temperature is 102° F.

Question 11

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 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.

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

Question 13

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.

Question 14

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 patient's 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 patient's position at least every 2 hours.

Question 15

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.

Question 16

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.
Correct

Question 17

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.

Question 18

A patient's 6 * f. 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)

Question 19

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.