Chapter 11: Inflammation and Wound
Healing Lewis: Medical-Surgical Nursing,
10th Edition
MULTIPLE CHOICE
1. The nurse assesses a patient’s surgical wound on the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is appropriate?
a.
Obtain wound cultures. c. Notify the health care provider.
b.
Document the assessment. 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) REF: 165
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a
band count of 11%. What prescribed action should the nurse take first?
a.
Obtain cultures of the wound.
b.
Begin antibiotic administration.
c.
Continue to monitor the wound for drainage.
d.
Redress the wound with wet-to-dry dressings.
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: Analyze (analysis) REF: 161
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
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 c. Rising body temperature
b.
Muscle cramps d. Decreasing blood pressure
ANS: C
The patient’s 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) REF: 164
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) The patient reports having no discomfort. Which action by the nurse is
appropriate?
a.
Apply a cooling blanket.
b.
Notify the health care provider.
c.
Check the patient’s temperature again in 4 hours.
d.
Give acetaminophen (Tylenol) prescribed PRN for pain.
ANS: C
Mild to moderate temperature elevations (<103° F) do not harm young adult patients 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,
and the patient does not require analgesics if not reporting discomfort. There is no need to
notify the patient’s health care provider or to use a cooling blanket for a moderate
temperature elevation.
DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. A patient’s 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 c. Hydrocolloid dressing
b.
Nonadherent dressing d. Transparent film dressing
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 clean 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) REF: 169
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
6. The nurse notes that a patient’s open abdominal wound widens as it extends deeper into
the abdomen. How would the nurse document this characteristic?
a.
Eschar c. Maceration
b.
Slough d. Undermining
ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a
narrower “lip” around the wound, which widens as the wound deepens. Eschar is a crusted
cover over a wound. Slough and maceration refer to loosening friable tissue.
DIF: Cognitive Level: Understand (comprehension) REF: 166
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which
nursing action is most likely to detect early signs of infection in this patient?
a.
Monitor white blood cell counts.
Healing Lewis: Medical-Surgical Nursing,
10th Edition
MULTIPLE CHOICE
1. The nurse assesses a patient’s surgical wound on the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is appropriate?
a.
Obtain wound cultures. c. Notify the health care provider.
b.
Document the assessment. 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) REF: 165
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a
band count of 11%. What prescribed action should the nurse take first?
a.
Obtain cultures of the wound.
b.
Begin antibiotic administration.
c.
Continue to monitor the wound for drainage.
d.
Redress the wound with wet-to-dry dressings.
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: Analyze (analysis) REF: 161
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
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 c. Rising body temperature
b.
Muscle cramps d. Decreasing blood pressure
ANS: C
The patient’s 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) REF: 164
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) The patient reports having no discomfort. Which action by the nurse is
appropriate?
a.
Apply a cooling blanket.
b.
Notify the health care provider.
c.
Check the patient’s temperature again in 4 hours.
d.
Give acetaminophen (Tylenol) prescribed PRN for pain.
ANS: C
Mild to moderate temperature elevations (<103° F) do not harm young adult patients 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,
and the patient does not require analgesics if not reporting discomfort. There is no need to
notify the patient’s health care provider or to use a cooling blanket for a moderate
temperature elevation.
DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. A patient’s 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 c. Hydrocolloid dressing
b.
Nonadherent dressing d. Transparent film dressing
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 clean 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) REF: 169
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
6. The nurse notes that a patient’s open abdominal wound widens as it extends deeper into
the abdomen. How would the nurse document this characteristic?
a.
Eschar c. Maceration
b.
Slough d. Undermining
ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a
narrower “lip” around the wound, which widens as the wound deepens. Eschar is a crusted
cover over a wound. Slough and maceration refer to loosening friable tissue.
DIF: Cognitive Level: Understand (comprehension) REF: 166
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which
nursing action is most likely to detect early signs of infection in this patient?
a.
Monitor white blood cell counts.
