1. A patient 1 day postoperative after abdominal
surgery has incisional pain, 99.5°F temperature,
slight erythema at the incision margins, and 30 mL
serosanguinous drainage in the Jackson-Pratt drain.
Based on this assessment, what conclusion would the
nurse make?
a. The patient has a normal inflammatory response.
b. The abdominal incision shows signs of an infection.
c. The abdominal incision shows signs of impending
dehiscence.
d. The patient’s health care provider must be notified
about her condition.
2. The nurse assessing a patient with a chronic leg
wound finds local signs of erythema, and the patient
reports pain at the wound site. What would the nurse
expect to be ordered to assess the patient’s systemic
response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of center of wound
d. Culture and sensitivity of the wound
3. A patient in the unit has a 103.7°F temperature.
Which intervention would be most effective in
restoring normal body temperature?
a. Using a cooling blanket while the patient is febrile
b. Giving antipyretics on an around-the-clock
schedule
c. Providing increased fluids and have the UAP give
, sponge baths
d. Giving prescribed antibiotics and placing warm
blankets for comfort
4. A nurse is caring for a patient who has a pressure
injury that is treated with debridement, irrigations,
and moist gauze dressings. How would the nurse
expect healing to occur?
a. Cell regeneration
b. Tertiary intention
c. Secondary intention
d. Remodeling of tissues
5. Which patient has the greatest risk for
experiencing delayed wound healing?
a. A 65-yr-old woman with stress incontinence
b. A 52-yr-old obese woman with type 2 diabetes
c. A 78-yr-old man who has a history of hypertension
d. A 30-yr-old man who drinks 2 alcoholic beverages
per day
6. Which order should a nurse question in the plan of
care for an older adult, immobile stroke patient with
a pink, clean stage 3 pressure injury?
a. Pack the wound with foam dressing.
b. Turn and position the patient every hour.
c. Clean the wound every shift with Dakin’s solution.
d. Assess for pain and medicate before dressing
change.
surgery has incisional pain, 99.5°F temperature,
slight erythema at the incision margins, and 30 mL
serosanguinous drainage in the Jackson-Pratt drain.
Based on this assessment, what conclusion would the
nurse make?
a. The patient has a normal inflammatory response.
b. The abdominal incision shows signs of an infection.
c. The abdominal incision shows signs of impending
dehiscence.
d. The patient’s health care provider must be notified
about her condition.
2. The nurse assessing a patient with a chronic leg
wound finds local signs of erythema, and the patient
reports pain at the wound site. What would the nurse
expect to be ordered to assess the patient’s systemic
response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of center of wound
d. Culture and sensitivity of the wound
3. A patient in the unit has a 103.7°F temperature.
Which intervention would be most effective in
restoring normal body temperature?
a. Using a cooling blanket while the patient is febrile
b. Giving antipyretics on an around-the-clock
schedule
c. Providing increased fluids and have the UAP give
, sponge baths
d. Giving prescribed antibiotics and placing warm
blankets for comfort
4. A nurse is caring for a patient who has a pressure
injury that is treated with debridement, irrigations,
and moist gauze dressings. How would the nurse
expect healing to occur?
a. Cell regeneration
b. Tertiary intention
c. Secondary intention
d. Remodeling of tissues
5. Which patient has the greatest risk for
experiencing delayed wound healing?
a. A 65-yr-old woman with stress incontinence
b. A 52-yr-old obese woman with type 2 diabetes
c. A 78-yr-old man who has a history of hypertension
d. A 30-yr-old man who drinks 2 alcoholic beverages
per day
6. Which order should a nurse question in the plan of
care for an older adult, immobile stroke patient with
a pink, clean stage 3 pressure injury?
a. Pack the wound with foam dressing.
b. Turn and position the patient every hour.
c. Clean the wound every shift with Dakin’s solution.
d. Assess for pain and medicate before dressing
change.
