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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 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. DIE: Cognitive Level: Application REE: 189 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. DIE: Cognitive Level: Application REE: 190 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 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 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 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. DIE: Cognitive Level: Application REE: 190 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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 MSC: NCLEX: Physiological Integrity 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 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 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. DIE: Cognitive Level: Application REE: 201-203 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity Test Bank Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 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. DIE: Cognitive Level: Application REE: 190-191 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 13-6 DIE: Cognitive Level: Application REE: 194 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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 MSC: NCLEX: SaIe and EIIective Care Environment 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. DIE: Cognitive Level: Application REE: 198 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: SaIe and EIIective Care Environment 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 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. DIE: Cognitive Level: Application REE: 192 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. DIE: Cognitive Level: Application REE: 194-195 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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 DIE: Cognitive Level: Application REE: 190 OBJ: Special Questions: Alternate Item Eormat TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an aIIiliate oI Elsevier, Inc. 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 MSC: NCLEX: Physiological Integrity