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Med Ser Inflammation and wound healing

Terms in this set (10)

. 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 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.
A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL 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.
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 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.
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.
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.
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 the mother?


a.
Change the patient's bedding frequently.
b.
Use a hydrocolloid dressing over the ulcer.
c.
Record the size and appearance of the ulcer weekly.
d.
Change the patient's 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 patient's position at least every 2 hours.
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 ankle's 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.
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.
Which finding is most important for the nurse to communicate to the health care provider when caring for 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.
After the home health nurse teaches a patient's 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.
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