Chapter 11 Inflammation and Wound Healing PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter11:InflammationandWoundHealing TestBank MULTIPLECHOICE 1.Thenurseassessesapatientssurgicalwoundonthefirstpostoperativedayandnotesrednessandwarmth aroundtheincision.Whichactionbythenurseismostappropriate? a.

Obtainwoundcultures.

b.

Documenttheassessment.

c.

Notifythehealthcareprovider.

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woundhasawhitebloodcell(WBC)countof13,500/Landabandcountof 11%.Whatactionshouldthenursetakefirst? a.

Obtainwoundcultures.

b.

Startantibiotictherapy.

c.

Redressthewoundwithwet-to-drydressings.

d.

Continuetomonitorthewoundforpurulentdrainage.

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:Apply(application)REF:161 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Planning MSC:NCLEX:PhysiologicalIntegrity

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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patients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:162 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).Whichactionbythenurseismostappropriate? a.

Applyacoolingblanket.

b.

Notifythehealthcareprovider.

c.

GivetheprescribedPRNaspirin(Ascriptin)650mg.

d.

Checkthepatientsoraltemperatureagainin4hours.

ANS:D Mildtomoderatetemperatureelevations(lessthan103F)donotharmtheyoungadultpatient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.Thereisnoneedtonotifythepatients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patients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(Kerlix)

b.

Nonadherentdressing(Xeroform)

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c.

Hydrocolloiddressing(DuoDerm)

d.

Transparentfilmdressing(Tegaderm)

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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 red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:170 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 6.Apatienthasanopensurgicalwoundontheabdomenthatcontainsdeeppinkgranulationtissue.How wouldthenursedocumentthiswound? a.

Redwound

b.

Yellowwound

c.

Full-thicknesswound

d.

StageIIIpressureulcer

ANS:A Thedescriptionisconsistentwitharedwound.AstageIIIpressureulcerwouldexposesubcutaneousfat.A yellowwoundwouldhavecreamycoloredexudate.Afull-thicknesswoundinvolvessubcutaneoustissue, whichisnotindicatedinthewounddescription. DIF:CognitiveLevel:Understand(comprehension)REF:167 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 7.Apatientwithrheumatoidarthritishasbeentakingcorticosteroidsfor11months.Whichnursingactionis mostlikelytodetectearlysignsofinfectioninthispatient? a.

Monitorwhitebloodcellcount.

b.

Checktheskinforareasofredness.

c.

Checkthetemperatureevery2hours.

d.

Askaboutfatigueorfeelingsofmalaise.

ANS:D Commonclinicalmanifestationsofinflammationandinfectionarefrequentlynotpresentwhenpatients

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receiveimmunosuppressivemedications.Theearliestmanifestationofaninfectionmaybejustnotfeeling well. DIF:CognitiveLevel:Apply(application)REF:164 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 8.Thenurseshouldplantouseawet-to-drydressingforwhichpatient? a.

Apatientwhohasapressureulcerwithpinkgranulationtissue

b.

Apatientwhohasasurgicalincisionwithpink,approximatededges

c.

Apatientwhohasafull-thicknessburnfilledwithdry,blackmaterial

d.

Apatientwhohasawoundwithpurulentdrainageanddrybrownareas

ANS:D Wet-to-drydressingsareusedwhenthereisminimaleschartoberemoved.Afull-thicknesswoundfilledwith escharwillrequireinterventionssuchassurgicaldebridementtoremovethenecrotictissue.Wet-to-dry dressingsarenotneededonapproximatedsurgicalincisions.Wet-to-drydressingsarenotusedonuninfected granulatingwoundsbecauseofthedamagetothegranulationtissue. DIF:CognitiveLevel:Apply(application)REF:175 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 9.Apatientfromalong-termcarefacilityisadmittedtothehospitalwithasacralpressureulcer.Thebaseof thewoundisyellowandinvolvessubcutaneoustissue.Howshouldthenurseclassifythispressureulcer? a.

StageI

b.

StageII

c.

StageIII

d.

StageIV

ANS:C AstageIIIpressureulcerhasfull-thicknessskindamageandextendsintothesubcutaneoustissue.AstageI pressureulcerhasintactskinwithsomeobservabledamagesuchasrednessoraboggyfeel.StageIIpressure ulcershavepartial-thicknessskinloss.StageIVpressureulcershavefull-thicknessdamagewithtissue necrosis,extensivedamage,ordamagetobone,muscle,orsupportingtissues. DIF:CognitiveLevel:Understand(comprehension)REF:173 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 10.AyoungmalepatientwhoisaparaplegichasastageIIsacralpressureulcerandisbeingcaredforathome byhismother.Topreventfurthertissuedamage,whatinstructionsaremostimportantforthenursetoteach

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themother? a.

Changethepatientsbeddingfrequently.

b.

Useahydrocolloiddressingovertheulcer.

c.

Recordthesizeandappearanceoftheulcerweekly.

d.

Changethepatientspositionatleastevery2hours.

ANS:D Themostimportantinterventionistoavoidprolongedpressureonbonyprominencesbyfrequent repositioning.Theotherinterventionsmayalsobeincludedinfamilyteaching,butthemostimportant instructionistochangethepatientspositionatleastevery2hours. DIF:CognitiveLevel:Apply(application)REF:172 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 11.Thenursewillperformwhichactionwhendoingawet-to-drydressingchangeonapatientsstageIIIsacral pressureulcer? a.

Soaktheolddressingswithsterilesaline30minutesbeforeremovingthem.

b.

Poursterilesalineontothenewdrydressingsafterthewoundhasbeenpacked.

c.

Applyantimicrobialointmentbeforerepackingthewoundwithmoistdressings.

d.

AdministertheorderedPRNhydrocodone(Lortab)30minutesbeforethedressingchange.

ANS:D Mechanicaldebridementwithwet-to-drydressingsispainful,andpatientsshouldreceivepainmedications beforethedressingchangebegins.Thenewdressingsaremoistenedwithsalinebeforebeingappliedtothe wound.Soakingtheolddressingsbeforeremovingthemwilleliminatethewounddebridementthatisthe purposeofthistypeofdressing.Applicationofantimicrobialointmentsisnotindicatedforawet-to-dry dressing. DIF:CognitiveLevel:Apply(application)REF:171 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 12.AnewnurseperformsadressingchangeonastageIIleftheelpressureulcer.Whichactionbythenew nurseindicatesaneedforfurtherteachingaboutpressureulcercare? a.

Thenewnurseusesahydrocolloiddressing(DuoDerm)tocovertheulcer.

b.

Thenewnurseinsertsasterilecotton-tippedapplicatorintothepressureulcer.

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c.

Thenewnurseirrigatesthepressureulcerwithsterilesalineusinga30-mLsyringe.

d.

Thenewnursecleanstheulcerwithasteriledressingsoakedinhalf-strengthperoxide.

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ANS:D Pressureulcersshouldnotbecleanedwithsolutionsthatarecytotoxic,suchashydrogenperoxide.Theother actionsbythenewnurseareappropriate. DIF:CognitiveLevel:Apply(application)REF:175 TOP:NursingProcess:EvaluationMSC:NCLEX:SafeandEffectiveCareEnvironment 13.Apatientarrivesintheemergencydepartmentwithaswollenankleafteraninjuryincurredwhileplaying soccer.Whichactionbythenurseismostappropriate? a.

Elevatetheankleaboveheartlevel.

b.

Applyawarmmoistpacktotheankle.

c.

Assesstheanklesrangeofmotion(ROM).

d.

Assesswhetherthepatientcanbearweightontheaffectedankle.

ANS:A Softtissueinjuriesaretreatedwithrest,ice,compression,andelevation(RICE).Elevationoftheanklewill decreasetissueswelling.MovingtheanklethroughtheROMwillincreaseswellingandriskfurtherinjury. Coldpacksshouldbeappliedthefirst24hourstoreduceswelling.Thenurseshouldnotaskthepatientto moveorbearweightontheswollenanklebecauseimmobilizationoftheinflamedorinjuredareapromotes healingbydecreasingmetabolicneedsofthetissues. DIF:CognitiveLevel:Apply(application)REF:165 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 14.WhenadmittingapatientwithstageIIIpressureulcersonbothheels,whichinformationobtainedbythe nursewillhavethemostimpactonwoundhealing? a.

Thepatienttakesinsulindaily.

b.

Thepatientstatesthattheulcersareverypainful.

c.

Thepatienthashadtheheelulcersforthelast6months.

d.

Thepatienthasseveraloldincisionsthathaveformedkeloids.

ANS:A Chronicinsulinuseindicatesdiabetes,whichcaninterferewithwoundhealing.Thepersistenceoftheulcers

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overthelast6monthsisaconcern,butchangesincaremaybeeffectiveinpromotinghealing.Keloidsarenot disablingorpainful,althoughthecosmeticeffectsmaybedistressingforsomepatients.Actionstoreducethe patientspainwillbeimplemented,butpaindoesnotdirectlyaffectwoundhealing. DIF:CognitiveLevel:Apply(application)REF:169 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 15.Afterreceivingachange-of-shiftreport,whichpatientshould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ulceronthecoccyx

c.

Thepatientwhohasbeenreceivingchemotherapyandhasatemperatureof102F

d.

Thepatientwhoneedstobemedicatedwithmultipleanalgesicsbeforeascheduleddressing change

ANS:C Chemotherapyisanimmunosuppressant.Evenalowfeverinanimmunosuppressedpatientisasignofserious infectionandshouldbetreatedimmediatelywithculturesandrapidinitiationofantibiotictherapy.Thenurse shouldassesstheotherpatientsassoonaspossibleafterassessingandimplementingappropriatecareforthe immunosuppressedpatient. DIF:CognitiveLevel:Analyze(analysis)REF:164 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:SafeandEffectiveCareEnvironment 16.Thenursecoulddelegatecareofwhichpatienttoalicensedpractical/vocationalnurse(LPN/LVN)? a.

Thepatientwhohasincreasedtendernessandswellingaroundalegwound

b.

Thepatientwhowasjustadmittedaftersuturingofafull-thicknessarmwound

c.

Thepatientwhoneedsteachingabouthomecareforadrainingabdominalwound

d.

ThepatientwhorequiresahydrocolloiddressingchangeforastageIIIsacralulcer

ANS:D LPN/LVNeducationandscopeofpracticeincludesteriledressingchangesforstablepatients.Initialwound assessments,patientteaching,andevaluationforpossiblepoorwoundhealingorinfectionshouldbedoneby theregisterednurse(RN). DIF:CognitiveLevel:Apply(application)REF:171 OBJ:SpecialQuestions:DelegationTOP:NursingProcess:Planning

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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MSC:NCLEX:SafeandEffectiveCareEnvironment 17.Thenurseiscaringforapatientwithdiabeteswhohadabdominalsurgery3daysago.Whichfindingis mostimportantforthenursetoreporttothehealthcareprovider? a.

Bloodglucose136mg/dL

b.

Oraltemperature101F(38.3C)

c.

Patientcomplaintofincreasedincisionalpain

d.

Separationoftheproximalwoundedgesby1cm

ANS:D Woundseparation3dayspostoperativelyindicatespossiblewounddehiscenceandshouldbeimmediately reportedtothehealthcareprovider.Theotherfindingswillalsobereportedbutdonotrequireinterventionas rapidly. DIF:CognitiveLevel:Apply(application)REF:168 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:PhysiologicalIntegrity 18.Apatientwhohasdiabetesisadmittedforanexploratorylaparotomyforabdominalpain.Whenplanning interventionstopromotewoundhealing,whatisthenurseshighestpriority? a.

Maintainingthepatientsbloodglucosewithinanormalrange

b.

Ensuringthatthepatienthasanadequatedietaryproteinintake

c.

Givingantipyreticstokeepthetemperaturelessthan102F(38.9C)

d.

Redressingthesurgicalincisionwithadry,steriledressingtwicedaily

ANS:A Elevatedbloodglucosewillhaveanimpactonmultiplefactorsinvolvedinwoundhealing.Ensuringadequate nutritionalsoisimportantforthepostoperativepatient,butahigherpriorityisbloodglucosecontrol.A temperatureof102Fwillnotimpactadverselyonwoundhealing,althoughthenursemayadminister antipyreticsifthepatientisuncomfortable.Applicationofadry,steriledressingdailymaybeordered,but frequentdressingchangesforawoundhealingbyprimaryintentionisnotnecessarytopromotewound healing. DIF:CognitiveLevel:Apply(application)REF:169 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Planning MSC:NCLEX:PhysiologicalIntegrity 19.Whichfindingismostimportantforthenursetocommunicatetothehealthcareproviderwhencaringfor

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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apatientwhoisreceivingnegativepressurewoundtherapy? a.

Lowserumalbuminlevel

b.

Serosanguineousdrainage

c.

Deepredandmoistwoundbed

d.

Cobblestoneappearanceofwound

ANS:A Withnegativepressuretherapy,serumproteinlevelsmaydecrease,whichwilladverselyaffectwoundhealing Theotherfindingsareexpectedwithwoundhealing. DIF:CognitiveLevel:Apply(application)REF:170 OBJ:SpecialQuestions:PrioritizationMSC:NCLEX:PhysiologicalIntegrity 20.Afterthehomehealthnurseteachesapatientsfamilymemberabouthowtocareforasacralpressureulcer, whichfindingindicatesthatadditionalteachingisneeded? a.

Thefamilymemberusesaliftsheettorepositionthepatient.

b.

Thefamilymemberusescleantapwatertocleanthewound.

c.

Thefamilymemberplacescontaminateddressingsinaplasticgrocerybag.

d.

Thefamilymemberdriesthewoundusingahairdryersetonalowsetting.

ANS:D Pressureulcersneedtobekeptmoisttofacilitatewoundhealing.Theotheractionsindicateagood understandingofpressureulcercare. DIF:CognitiveLevel:Apply(application)REF:175 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity SHORTANSWER 1.Apatientstemperaturehasbeen101F(38.3C)forseveraldays.Thepatientsnormalcaloricintaketomeet nutritionalneedsis2000caloriesperday.Knowingthatthemetabolicrateincreases7%foreachFahrenheit degreeabove100inbodytemperature,howmanytotalcaloriesshouldthepatientreceiveeachday? ANS: 2140calories DIF:CognitiveLevel:Apply(application)REF:164 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity

TestBank-Medical-SurgicalNursing:AssessmentandMa...