Chapter 13: Palliative and End-of-Life Care:
Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient with a systemic bacterial infection who has "goose
pimples," feels cold, and rigors. At this stage of the febrile response, which of the
following assessments should the nurse monitor?
A. Skin flushing
B. Muscle cramps
C. Rising body temperature
D. Decreasing blood pressure
Answer: C
Explanation: The symptoms described (chills, rigors, feeling cold) occur during the chill
phase of a fever, when the body's hypothalamic set-point has increased. The body is actively
generating heat to raise its core temperature to this new set-point, so the nurse should
anticipate and monitor for a rising body temperature.
2. The nurse is planning care for a patient and is preparing to complete a wet-to-dry
dressing. Which of the following wound descriptions is appropriate for using this type
of dressing?
A. Pressure injury with pink granulation tissue
B. Surgical incision with pink, approximated edges
C. Full-thickness burn filled with dry, black material
D. Wound with purulent drainage and dry brown areas
Answer: D
Explanation: Wet-to-dry dressings are a form of mechanical debridement used to remove
small amounts of necrotic tissue (eschar) or slough. They are not used on clean, granulating
wounds (Option A), approximated incisions (Option B), or wounds filled with thick, hard
eschar that requires surgical debridement (Option C).
3. The nurse is admitting a patient with stage 3 pressure injuries on both heels. Which
of the following information obtained by the nurse will have the most impact on wound
healing?
A. The patient states that the injuries are very painful.
B. The patient has had the heel injuries for the last 6 months.
C. The patient has several old incisions that have formed keloids.
D. The patient takes corticosteroids daily for rheumatoid arthritis.
Answer: D
,Explanation: Corticosteroids suppress the inflammatory response and impair collagen
synthesis, both of which are critical for wound healing. This systemic factor will have a
significant negative impact on healing. While chronicity (B) and pain (A) are concerns, they
do not directly inhibit the cellular healing process like corticosteroids do. Keloid formation
(C) is a cosmetic issue related to overhealing.
4. The nurse is caring for a patient with diabetes who had abdominal surgery one week
ago, and obtains the following data. Which of these findings should be reported
immediately to the health care provider?
A. Blood glucose 7.6 mmol/L
B. Oral temperature 38.3°C (100.9°F)
C. Patient has increased incisional pain
D. New 5-cm separation of the proximal wound edges
Answer: D
Explanation: A new separation of the wound edges one week postoperatively is a sign of
possible wound dehiscence, which is a surgical emergency. This requires immediate
notification of the surgeon. The other findings (mild fever, elevated but not critical glucose,
increased pain) should be addressed but do not indicate an imminent complication like
dehiscence.
5. The nurse is caring for a young adult patient who is receiving antibiotics for an
infected leg wound and has a temperature of 38.8°C (101.8°F). Which of the following
actions by the nurse is most appropriate?
A. Apply a cooling blanket.
B. Notify the health care provider.
C. Give the prescribed PRN Aspirin 650 mg.
D. Check the patient's oral temperature again in 4 hours.
Answer: D
Explanation: A moderate fever can enhance the immune response and is not typically
harmful to a young adult. The patient is already on antibiotics to treat the underlying
infection. The most appropriate action is to continue monitoring. Antipyretics are usually
reserved for higher fevers or patient discomfort, and a cooling blanket is not indicated.
6. A patient who is confined to bed and who has a stage 2 pressure injury is being cared
for in the home by family members. To prevent further tissue damage, which of the
following actions should the nurse instruct the family members that it is most
important?
A. Change the patient's bedding frequently.
B. Use a hydrocolloid dressing over the injury.
C. Record the size and appearance of the pressure injury weekly.
D. Change the patient's position every 2 hours.
, Answer: D
Explanation: The primary cause of pressure injuries is prolonged pressure. The single most
important preventive measure is frequent repositioning to relieve pressure on bony
prominences. While the other actions are part of good care, they do not address the
fundamental cause of the injury.
7. The nurse has just received change-of-shift report about the following four patients.
Which patient will the nurse assess first?
A. The patient who has multiple black wounds on the feet and ankles.
B. The newly admitted patient with a stage IV pressure injury on the coccyx.
C. The patient who needs to be medicated with multiple analgesics before a scheduled
dressing change.
D. The patient who has been receiving immunosuppressant medications and has a
temperature of 38.9°C (102°F).
Answer: D
Explanation: A fever in an immunocompromised patient is a potential medical emergency,
as they may not mount a typical immune response until an infection is severe. This patient
requires immediate assessment for sepsis. The other patients have chronic or scheduled needs
that are important but not as immediately life-threatening.
8. The nurse is caring for a patient who has an open surgical wound on the abdomen
that contains a creamy exudate and small areas of deep pink granulation tissue. Which
of the following terms should the nurse use to document these findings?
A. Red wound
B. Yellow wound
C. Full-thickness wound
D. Stage III pressure wound
Answer: B
Explanation: The presence of a creamy exudate (slough) classifies this as a "yellow wound"
according to the Red-Yellow-Black wound classification system. This system guides
treatment based on wound appearance rather than depth or etiology.
9. The nurse is assessing a patient the morning of the first postoperative day and notes
redness and warmth around the incision. Which of the following actions should the
nurse implement?
A. Obtain wound cultures.
B. Document the assessment.
C. Notify the health care provider.
D. Assess the wound every 2 hours.
Answer: B
Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient with a systemic bacterial infection who has "goose
pimples," feels cold, and rigors. At this stage of the febrile response, which of the
following assessments should the nurse monitor?
A. Skin flushing
B. Muscle cramps
C. Rising body temperature
D. Decreasing blood pressure
Answer: C
Explanation: The symptoms described (chills, rigors, feeling cold) occur during the chill
phase of a fever, when the body's hypothalamic set-point has increased. The body is actively
generating heat to raise its core temperature to this new set-point, so the nurse should
anticipate and monitor for a rising body temperature.
2. The nurse is planning care for a patient and is preparing to complete a wet-to-dry
dressing. Which of the following wound descriptions is appropriate for using this type
of dressing?
A. Pressure injury with pink granulation tissue
B. Surgical incision with pink, approximated edges
C. Full-thickness burn filled with dry, black material
D. Wound with purulent drainage and dry brown areas
Answer: D
Explanation: Wet-to-dry dressings are a form of mechanical debridement used to remove
small amounts of necrotic tissue (eschar) or slough. They are not used on clean, granulating
wounds (Option A), approximated incisions (Option B), or wounds filled with thick, hard
eschar that requires surgical debridement (Option C).
3. The nurse is admitting a patient with stage 3 pressure injuries on both heels. Which
of the following information obtained by the nurse will have the most impact on wound
healing?
A. The patient states that the injuries are very painful.
B. The patient has had the heel injuries for the last 6 months.
C. The patient has several old incisions that have formed keloids.
D. The patient takes corticosteroids daily for rheumatoid arthritis.
Answer: D
,Explanation: Corticosteroids suppress the inflammatory response and impair collagen
synthesis, both of which are critical for wound healing. This systemic factor will have a
significant negative impact on healing. While chronicity (B) and pain (A) are concerns, they
do not directly inhibit the cellular healing process like corticosteroids do. Keloid formation
(C) is a cosmetic issue related to overhealing.
4. The nurse is caring for a patient with diabetes who had abdominal surgery one week
ago, and obtains the following data. Which of these findings should be reported
immediately to the health care provider?
A. Blood glucose 7.6 mmol/L
B. Oral temperature 38.3°C (100.9°F)
C. Patient has increased incisional pain
D. New 5-cm separation of the proximal wound edges
Answer: D
Explanation: A new separation of the wound edges one week postoperatively is a sign of
possible wound dehiscence, which is a surgical emergency. This requires immediate
notification of the surgeon. The other findings (mild fever, elevated but not critical glucose,
increased pain) should be addressed but do not indicate an imminent complication like
dehiscence.
5. The nurse is caring for a young adult patient who is receiving antibiotics for an
infected leg wound and has a temperature of 38.8°C (101.8°F). Which of the following
actions by the nurse is most appropriate?
A. Apply a cooling blanket.
B. Notify the health care provider.
C. Give the prescribed PRN Aspirin 650 mg.
D. Check the patient's oral temperature again in 4 hours.
Answer: D
Explanation: A moderate fever can enhance the immune response and is not typically
harmful to a young adult. The patient is already on antibiotics to treat the underlying
infection. The most appropriate action is to continue monitoring. Antipyretics are usually
reserved for higher fevers or patient discomfort, and a cooling blanket is not indicated.
6. A patient who is confined to bed and who has a stage 2 pressure injury is being cared
for in the home by family members. To prevent further tissue damage, which of the
following actions should the nurse instruct the family members that it is most
important?
A. Change the patient's bedding frequently.
B. Use a hydrocolloid dressing over the injury.
C. Record the size and appearance of the pressure injury weekly.
D. Change the patient's position every 2 hours.
, Answer: D
Explanation: The primary cause of pressure injuries is prolonged pressure. The single most
important preventive measure is frequent repositioning to relieve pressure on bony
prominences. While the other actions are part of good care, they do not address the
fundamental cause of the injury.
7. The nurse has just received change-of-shift report about the following four patients.
Which patient will the nurse assess first?
A. The patient who has multiple black wounds on the feet and ankles.
B. The newly admitted patient with a stage IV pressure injury on the coccyx.
C. The patient who needs to be medicated with multiple analgesics before a scheduled
dressing change.
D. The patient who has been receiving immunosuppressant medications and has a
temperature of 38.9°C (102°F).
Answer: D
Explanation: A fever in an immunocompromised patient is a potential medical emergency,
as they may not mount a typical immune response until an infection is severe. This patient
requires immediate assessment for sepsis. The other patients have chronic or scheduled needs
that are important but not as immediately life-threatening.
8. The nurse is caring for a patient who has an open surgical wound on the abdomen
that contains a creamy exudate and small areas of deep pink granulation tissue. Which
of the following terms should the nurse use to document these findings?
A. Red wound
B. Yellow wound
C. Full-thickness wound
D. Stage III pressure wound
Answer: B
Explanation: The presence of a creamy exudate (slough) classifies this as a "yellow wound"
according to the Red-Yellow-Black wound classification system. This system guides
treatment based on wound appearance rather than depth or etiology.
9. The nurse is assessing a patient the morning of the first postoperative day and notes
redness and warmth around the incision. Which of the following actions should the
nurse implement?
A. Obtain wound cultures.
B. Document the assessment.
C. Notify the health care provider.
D. Assess the wound every 2 hours.
Answer: B
