Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 91
Chapter 11: Inflammation and Healing
Test Bank
MULTIPLE CHOICE
1. The nurse assesses a patients surgical wound on 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.
ANS: B
The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing
by primary intention. The nurse should document the wound appearance and continue to monitor the wound.
Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not
indicated because the healing is progressing normally.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of
11%. What action should the nurse take first?
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.
ANS: A
The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a
bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes
may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional
actions are needed as well.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 92
3. A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding
will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
ANS: C
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 a rising temperature.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. A young adult 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 patients oral temperature again in 4 hours.
ANS: D
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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. A patients 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green
semiliquid material. Which dressing should the nurse apply to the wound?
a. Dry gauze dressing (Kerlix)
b. Nonadherent dressing (Xeroform)
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 93
c. Hydrocolloid dressing (DuoDerm)
d. Transparent film dressing (Tegaderm)
ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. 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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
6. A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How
would the nurse document this wound?
a. Red wound
b. Yellow wound
c. Full-thickness wound
d. Stage III pressure ulcer
ANS: A
The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A
yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue,
which is not indicated in the wound description.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is
most likely to detect early signs of infection in this patient?
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.
ANS: D
Common clinical manifestations of inflammation and infection are frequently not present when patients
, Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 94
receive immunosuppressive medications. The earliest manifestation of an infection may be just not feeling
well.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas
ANS: D
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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of
the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: C
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.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
10. A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home
by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach
Chapter 11: Inflammation and Healing
Test Bank
MULTIPLE CHOICE
1. The nurse assesses a patients surgical wound on 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.
ANS: B
The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing
by primary intention. The nurse should document the wound appearance and continue to monitor the wound.
Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not
indicated because the healing is progressing normally.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of
11%. What action should the nurse take first?
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.
ANS: A
The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a
bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes
may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional
actions are needed as well.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 92
3. A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding
will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
ANS: C
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 a rising temperature.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. A young adult 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 patients oral temperature again in 4 hours.
ANS: D
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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. A patients 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green
semiliquid material. Which dressing should the nurse apply to the wound?
a. Dry gauze dressing (Kerlix)
b. Nonadherent dressing (Xeroform)
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 93
c. Hydrocolloid dressing (DuoDerm)
d. Transparent film dressing (Tegaderm)
ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. 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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
6. A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How
would the nurse document this wound?
a. Red wound
b. Yellow wound
c. Full-thickness wound
d. Stage III pressure ulcer
ANS: A
The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A
yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue,
which is not indicated in the wound description.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is
most likely to detect early signs of infection in this patient?
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.
ANS: D
Common clinical manifestations of inflammation and infection are frequently not present when patients
, Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 94
receive immunosuppressive medications. The earliest manifestation of an infection may be just not feeling
well.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas
ANS: D
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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of
the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: C
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.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
10. A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home
by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach
