Chapter 11: Inflammation and Wound Healing

Chapter 11: Inflammation and Wound Healing

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

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?

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?

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?

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?

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