Chapter 13: Inflammation and Wound Healing

Chapter 13: Inflammation and Wound Healing

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. The nurse assesses a surgical patient the morning of 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: Application REF: 192
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient with an open abdominal wound has a complete blood cell (CBC) count and
differential, which indicate an increase in white blood cells (WBCs) and a shift to the left.
The nurse anticipates that the next action will be to
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 shift to the left indicates that the patient probably has a bacterial infection, and the
nurse will plan to 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: Application REF: 187 | 199 TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
3. A patient with a systemic bacterial infection has “goose pimples,” feels cold, and has a
shaking chill. At this stage of the febrile response, the nurse will plan to monitor for
a. skin flushing.
b. muscle cramps.
c. rising body temperature.
Test Bank 13-2
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 rising temperatures.
DIF: Cognitive Level: Application REF: 189
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. A 24-year-old 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 patient’s 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 patient’s health care provider or to use a
cooling blanket for a moderate temperature elevation.
DIF: Cognitive Level: Application REF: 190
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity