Lewis Med-Surg Ch. 11 Inflammation and Wound Healing Exam Practice Questions and Answers

Lewis Med-Surg Ch. 11 Inflammation and Wound Healing Exam Practice Questions and Answers 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:-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) 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. ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/15 b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings. - Ans:-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) 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:-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. ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/15 DIF: Cognitive Level: Apply (application) 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:-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) A patient's 4 x 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? ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/15 a. Dry gauze dressing c. Hydrocolloid dressing b. Nonadherent dressing d. Transparent film dressing - Ans:-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) 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. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise. - Ans:-ANS: D