C11 - ch 11 test bank PDF

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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? c. Notify the health care provider. d. Assess the wound every 2 hours.

a. Obtain wound cultures. b. Document the assessment. 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? Obtain cultures of the wound. Begin antibiotic administration. Continue to monitor the wound for drainage. Redress the wound with wet-to-dry dressings.

a. b. c. d.

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 b. Muscle cramps

c. Rising body temperature 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 (...